Peripapillary pachychoroid syndrome successfully treated with topical prednisolone acetate 1% drops.

Peripapillary pachychoroid syndrome (PPS) is a rare disease characterized by choroidal thickening around the optic disc. Visual acuity might be impaired secondary to the associated peripapillary intraretinal and/or subretinal fluids. We reported a case of a 70-year-old male patient who presented with a gradual bilateral decrease in vision. His best-corrected visual acuity was 20/60 in the right eye and 20/25 in the left eye. Dilated fundus examination showed yellowish peripapillary lesions and intraretinal fluid (IRF) surrounding the optic disc in both eyes. Optical coherence tomography showed that the outer retinal layers were disrupted, and IRF affected the nasal macula. A bilateral increase in the thickness of the choroid around the optic discs was found. The patient was successfully treated with a tapering dose of topical prednisolone acetate (1%). Three months after treatment, his vision improved to 20/25 in the right eye and 20/20 in the left eye. Topical steroid drops might be administered to treat PPS.

Alterations in ocular microcirculation and oxygen metabolism in patients with lipemia retinalis.

PURPOSE: The study aims to assess the alterations in retinal oxygen saturation and retinal and choroidal blood flow in lipemia retinalis. METHODS: This was a cross-sectional study on 10 eyes (5 patients) with history of lipemia retinalis. The study comprised 10 eyes with documented history of lipemia retinalis and 10 participants as healthy controls. Patients with a confirmed history of lipemia retinalis were grouped into two cohorts based on their most recent fundus examination: untreated lipemia retinalis (abnormal fundus) and resolved lipemia retinalis (normal fundus). Both retinal arteriolar and venular oxygen saturation were measured using the non-invasive spectrophotometric retinal oximeter (Oxymap T1). The mean blur rate (MBR) of the optic nerve and choroidal blood flow were analyzed using a laser speckle flowgraph (LSFG). RESULTS: Patients with untreated lipemia retinalis had a significantly higher retinal arteriolar and venular oxygen saturation than that of the other two groups (p < 0.001). Moreover, patients with untreated lipemia retinalis had significantly smaller retinal arteriolar and venular diameters (p < 0.001). On LSFG, there was a significant difference in the overall MBR (p = 0.007) and vessel MBR of the optic nerve between the groups (p = 0.011). The patients with history of lipemia retinalis (untreated and resolved) exhibited a high overall MBR and vessel MBR of the optic nerve than that of the control group. There was a significant elevation of the optic nerve (p = 0.002) and choroidal blowout score (p < 0.001), while the resistivity index of the optic nerve (p = 0.001) and choroids (p = 0.002) was significantly lower in patients with resolved and untreated lipemia retinalis. CONCLUSIONS: There was a significant alteration in retinal oximetry, in untreated lipemia retinalis, and in retinal blood flow, in both the resolved and untreated groups. The increase in retinal blood flow and oxygen saturation may elucidate the preservation of visual acuity and function despite the fundus changes observed in lipemia retinalis.

Laser-Induced Maculopathy Masquerading as Hereditary Macular Dystrophy.

There has been an emergence of permanent macular injury due to the misuse of handheld laser pointers. The clinical phenotype of laser-induced maculopathy can mimic hereditary retinal dystrophies. This report describes the clinical phenotype and the results of multimodal imaging in a 27-year-old woman who was referred with a bilateral progressive decrease in vision over 2 months. She was initially diagnosed elsewhere with hereditary macular dystrophy. Examination of her fundus showed bilateral creamy-to-gray irregular lesions in the posterior pole. The results of multimodal imaging of her retina suggested self-inflicted laser-induced maculopathy. The patient was referred to a psychiatrist with a working diagnosis of factitious disorder. A high index of suspicion and the utilization of multimodal imaging allowed early and correct diagnosis and prevented further loss of vision.

Knowledge, Attitude, and Practices (KAP) of Diabetics Towards Diabetes and Diabetic Retinopathy in Riyadh, Saudi Arabia: Cross-Sectional Study.

BACKGROUND: Diabetes mellitus (DM) and its complication present a major morbidity burden among Saudi population. Awareness and proper knowledge of this highly prevalent disease is crucial to enhance early detection and proper intervention. Therefore, the main aim of this study was to identify the knowledge, attitude, and practices (KAP) of diabetic patients towards diabetes and diabetic retinopathy in Riyadh, Saudi Arabia. METHODS: This cross-sectional study was conducted in 50 randomly selected primary care centers and two university hospitals in Riyadh, Saudi Arabia, between May and December 2018. Diabetic patients ≥18 years old were enrolled in the study. A validated KAP-45 questionnaire was used to assess the KAP levels of diabetics towards diabetes and diabetic retinopathy. RESULTS: A total of 313 participants were enrolled in the study. The majority were males 168 (59.8%). The median age was 49 ±24, and the median duration of diabetes was 8 ±11 years. The average knowledge score for diabetes was 10 (good). While the average knowledge score for diabetic retinopathy was 4.5 (suboptimal). The average attitude scores for both diabetes and diabetic retinopathy were 0 and 2 (suboptimal), respectively. The average practice score for diabetes was 5 (good) while it was 3 (low) for diabetic retinopathy. The most common barrier to comply with regular follow-up was inadequate knowledge about the importance of periodic eye exam 47.1% (107). Patients with low socio-economic status had a significantly poor knowledge regarding diabetes (P<0.0001) and diabetic retinopathy (P<0.015), respectively. However, patients with low educational level had a significantly poor knowledge (p<0.0001) and poor practice regarding diabetes (P<0.013), respectively. CONCLUSION: It is important to improve education and awareness of DM and diabetic retinopathy among diabetics, as it's essential for controlling the disease and reducing its complications, by improving patient compliance to treatment and follow-up.

Patient Satisfaction Toward a Tele-Retinal Screening Program in Endocrinology Clinics at a Tertiary Hospital in Riyadh, Saudi Arabia.

PURPOSE: Tele-retinal screening programs use a nonmydriatic camera for retinal imaging. These images are reviewed by ophthalmologists, for interpretation and planning of appropriate treatment and follow up. Patient satisfaction is a critical tool to assess the quality of healthcare delivery and to reframe the current screening programs. The aim of this study is to measure satisfaction toward a tele-retinal screening program among diabetics attending endocrinology clinics at a tertiary hospital in Riyadh.  Methods: This is a cross-sectional study that included a total of 163 patients recruited while attending tele-retinal screening at King Abdul-Aziz University Hospital in Riyadh, during the period between May and August 2019. A self-administrated Patient Satisfaction Questionnaire PSQ18 was used which included demographic data, diabetes history, and seven domains of satisfaction that were measured.  Results: Some 54% of the respondents were male. The average age was 44.8 years. Some 49.7% had type 2 diabetes. The mean duration of diabetes was 15.3 years. The overall satisfaction level was 80.4%. The highest satisfaction rate was in the interpersonal manner (mean 4.45) while the lowest was in accessibility to an ophthalmologist when a referral was needed (mean 3.01). Some 60% of the participants were concerned it might take a long time to be referred to an ophthalmologist when it is needed. Some 90.1% found it easier to have diabetic retinopathy (DR) screening during routine diabetes follow up. Some 23.9% did not like the idea of only seeing the ophthalmologist when it is necessary and only 9.8% had some doubts of the doctor's ability to diagnose DR by evaluating retina photos only. No significant association was found between patient's satisfaction and demographic background or diabetes history. CONCLUSION:  Patients were found to be highly satisfied with tele-retinal screening program. Mostly the reason of dissatisfaction was found in accessibility to an ophthalmologist when a referral was needed. Therefore, it is important to reassure patients that timely referral for effective intervention is performed and part of the screening policies.

Screening for obstructive sleep apnea amongst patients with retinal vein occlusion.

OBJECTIVE: To evaluate the prevalence and varying severity of obstructive sleep apnea (OSA) amongst those newly diagnosed with retinal vein occlusion (RVO), and screen patients with the use of 2 in-office-administered questionnaires validated against polysomnography. DESIGN: Prospective cross-sectional study. PARTICIPANTS: Consecutive adult patients (≥18 years of age) with a new diagnosis of RVO confirmed with intravenous fluorescein angiography were enrolled. METHODS: The study was conducted at a tertiary academic centre between March 22, 2017, and April 7, 2018. Patients completed the Berlin and STOP-BANG questionnaires screening for OSA at presentation. Diagnostic test properties of the 2 questionnaires compared with polysomnography at a certified sleep laboratory centre as the gold standard for detection of OSA were calculated. RESULTS: A total of 27 patients (37% females) with a mean (standard deviation) age of 69.6 (11.5) years completed the study. The diagnosis of OSA based on polysomnography was made in 96% (41% severe OSA) of patients with RVO. The Berlin questionnaire had a sensitivity of 43% (confidence interval [CI]: 22%-66%) and specificity of 67% (CI: 22%-96%). The STOP-BANG questionnaire had a sensitivity of 86% (CI: 64%-97%) and specificity of 50% (CI: 12%-88%). CONCLUSIONS: Given the high prevalence of severe OSA amongst those with a new diagnosis of RVO, all patients should be strongly considered for polysomnography. The use of in-office questionnaires may aid in triaging urgency of referrals.

Hydroxychloroquine dosing and toxicity: A real-world experience in Saudi Arabia of 63 patients.

PURPOSE: To assess the ocular toxicity in patients on high doses of hydroxychloroquine (HCQ) per weight, as per the latest American Academy of Ophthalmology (AAO) screening guidelines for HCQ toxicity. METHODS: This is a multi-center study looking at consecutive patients attending the ophthalmology clinics at a tertiary hospital and a private clinic in Saudi Arabia. A data collection sheet was used to collect patient's information regarding the dose per body weight, duration of HCQ use and any risk factors associated with the use of the medication as per the latest AAO guidelines for HCQ screening. Ancillary testing including fundus photography, automated visual field (10-2) and spectral domain ocular coherence tomography were done. Further testing with fundus auto-fluorescence and multifocal ERG were done when needed. The presence or absence of toxicity was recorded. RESULTS: A total of 63 patients were included in the study, 58 females and 5 males. The average patient age was 45 years (range 18-72). The mean dosage of HCQ was 3.9 mg/kg. Fourteen (22%) patients were on doses higher than 5 mg/kg. The duration of treatment ranged from 1-30 years (average 8.3). Thirty six (57%) patients were on the drug for more than 5 years. We found only one (1.58%) patient with HCQ toxic retinopathy over a mean of 8 years treatment period. CONCLUSION: A significant number of our patients were found to be on doses of >5 mg/kg of HCQ, which may put them at a higher risk for retinal toxicity. Low dose HCQ such as 100 mg tablets should be made available to help physicians in adjusting the dose as per the latest reported guidelines by the AAO.

The validity of diabetic retinopathy screening using nonmydriatic fundus camera and optical coherence tomography in comparison to clinical examination.

PURPOSE: To evaluate the use of non-mydriatic fundus camera as a screening modality for diabetic retinopathy in a sample of population in Riyadh, Saudi Arabia. METHODS: Patients coming, from April 2015 till September 2018, for their diabetic check up at the diabetic center clinics in King Abdul-Aziz University hospital were screened using a non-mydriatic fundus camera (NMFC). Photos were graded by retina specialist and compared to the findings of dilated fundus examination (DFE) by retina specialists. RESULTS: The grading results of NMFC and DFE were compared and the overall sensitivity and specificity for detection of diabetic retinopathy within one grade of retinopathy was 98.7% and 80% respectively. The sensitivity for detection of sight threatening conditions such as proliferative diabetic retinopathy, severe non-proliferative diabetic retinopathy, and diabetic macular edema (by Ocular Coherence Tomography) was found to be 86.7%, 90.3% and 100% respectively; while the specificity was found to be 96.5%, 93%, and 100% respectively. CONCLUSION: Non-mydriatic fundus camera has a high sensitivity and specificity in screening for diabetic retinopathy. It is a great screening tool, which is user friendly and can be operated by trained nurses in primary clinics during patient's regular routine diabetic checkups. It aids in early detection of sight threatening conditions which need urgent referral to ophthalmologists.

Deep learning based computer-aided diagnosis systems for diabetic retinopathy: A survey.

Diabetic retinopathy (DR) results in vision loss if not treated early. A computer-aided diagnosis (CAD) system based on retinal fundus images is an efficient and effective method for early DR diagnosis and assisting experts. A computer-aided diagnosis (CAD) system involves various stages like detection, segmentation and classification of lesions in fundus images. Many traditional machine-learning (ML) techniques based on hand-engineered features have been introduced. The recent emergence of deep learning (DL) and its decisive victory over traditional ML methods for various applications motivated the researchers to employ it for DR diagnosis, and many deep-learning-based methods have been introduced. In this paper, we review these methods, highlighting their pros and cons. In addition, we point out the challenges to be addressed in designing and learning about efficient, effective and robust deep-learning algorithms for various problems in DR diagnosis and draw attention to directions for future research.

Non-mydriatic fundus camera screening with diagnosis by telemedicine for diabetic retinopathy patients with type 1 and type 2 diabetes: a hospital-based cross-sectional study.

BACKGROUND: Diabetic retinopathy (DR) is considered the fifth leading cause of visual impairment worldwide and is associated with a huge social and economic burden. OBJECTIVE: Describe the practicality of non-mydriatic funduscopic screening photography for the detection of DR among patients with type 1 and type 2 diabetes. DESIGN: Cross-sectional hospital-based study. SETTING: Diabetes center, Riyadh. PATIENTS AND METHODS: Between July and December 2017, patients with diabetes and aged ≥18 years were selected by systematic random sampling from the University Diabetes Center. Fundoscopic eye examination was performed using the TRC-NW8 non-mydriatic camera, which performs ocular coherence tomography (OCT) to detect macular edema. Using telemedicine, pictures were graded by a retinal-specialized ophthalmologist using the international clinical DR disease severity scale. Patients were classified according to the type and severity of DR. MAIN OUTCOME MEASURES: Detection and classification of DR. SAMPLE SIZE: 978 Saudi patients with diabetes. RESULTS: Of 426 (43.5%) patients with DR, 370 had nonproliferative DR and 55 had proliferative DR. Nineteen (1.9%) had macular edema. The most important risk factors for DR were longer diabetes duration and poor glycemic control. Both older age and insulin use contributed to the higher prevalence of DR and macular edema. DR was more common among type 1 patients at 55.4% compared with 49% among type 2 patients. In addition, more females had macular edema (57.1% versus 42.9% among males). Nine patients with macular edema (47.3%) had hypertension while 154 of 426 patients with DR (36.2%) had hypertension. CONCLUSION: Non-mydriatic funduscopic screening photography was practical and useful for the detection of DR in patients with type 1 and type 2 diabetes. LIMITATIONS: Conducted in a single center. CONFLICT OF INTEREST: None.

Barriers for Adherence to Diabetic Retinopathy Screening among Saudi Adults.

Background Diabetic retinopathy (DR) is one of the major complications of diabetes mellitus (DM) and the leading cause of blindness among adults. However, adherence to diabetic retinopathy screening (DRS) significantly reduces blindness. A substantial proportion of diabetics have suboptimal compliance to DRS, which inversely affects their outcomes. Therefore, the aim of this study is to determine the level of adherence to DRS and to explore the factors possibly associated with poor adherence to regular screening among diabetics in Riyadh, Saudi Arabia. Method A cross-sectional study was conducted that encompassed 404 adult diabetic patients attending outpatient clinics in four hospitals in Riyadh. A validated, self-administered questionnaire was used for data collection that included five main sections: sociodemographic data, diabetic profile, assessment of knowledge about DR, attitude toward DRS, and barriers to DRS. Data were analyzed by SPSS, version 23 (IBM Corp., Armonk, NY); qualitative variables were described as percentages, and quantitative variables were described as means ± standard deviation (SD). We used the chi-square test to measure the associations between qualitative variables and binary logistic regression analysis to predict the independent barriers to DRS. Result The average age of the participants was 54 years, and 69.1% were females. The average duration of diabetes was 12.3 years. Type 2 DM was the most prevalent form of DM (63.6%). DR was reported by 20% of participants. Poor knowledge about DRS was prevalent in 51%. More than one-fifth were never screened for DR. About one-third of participants agreed that cost was an important contributing barrier. Adequate knowledge, increased duration of diabetes, and presence of neurological complications increased independent adherence to screening. Conclusion One-fifth of participants reported having DR. Half the participants had poor knowledge about DR, which formed a major barrier against regular screening. However, most participants had positive attitudes about DR screening. Therefore, intervention strategies to increase patients' awareness of DR might be the cornerstone of ensuring proper adherence to DRS.

EFFECT OF AN INTRAVITREAL DEXAMETHASONE IMPLANT ON DIABETIC MACULAR EDEMA AFTER CATARACT SURGERY.

PURPOSE: To analyze the effects of a dexamethasone intravitreal implant (DEX; Ozurdex 700 µg; Allergan) administered immediately after cataract surgery in diabetic patients. METHODS: This prospective, single-arm, open label study (NCT01748487 at ClinicalTrials.gov) involved Type 2 diabetic patients with at least mild diabetic retinopathy (DR) who underwent cataract surgery and DEX insertion after phacoemulsification, and intraocular lens implantation were enrolled. Best-corrected visual acuity and central retinal thickness (CRT) measured by spectral-domain optical coherence tomography were recorded at 1 week preoperatively, and 1 week, 1 month, and 3 months after surgery. Adverse events were also recorded. RESULTS: Twenty-four eyes of 24 patients (17 [70.8%] men; mean age 63.7 ± 8.7 years) with mild nonproliferative DR (41.7%), moderate nonproliferative DR (33.3%), severe nonproliferative DR (16.7%), or treated proliferative DR (8.3%) were selected. After DEX treatment, mean CRT changed from 241.1 µm (95% confidence interval, 227.5-254.6 µm) at baseline to 236.9 µm (95% confidence interval, 223.9-249.9 µm) at 1 week (P = 0.09), 238.9 µm (95% confidence interval, 225.5-252.3 µm) at 1 month (P = 0.44), and 248 µm (95% confidence interval, 232.4-260.8 µm) at 3 months (P = 0.15). No eyes showed a postoperative increase >50 µm in the CRT at any visit. A 10% increase in CRT was found in 8.3% of eyes. Mean best-corrected visual acuity significantly improved from 0.37 (20/50) at baseline to 0.19 (20/30) at 1 week, 0.12 (20/25) at 1 month, and 0.12 (20/25) at 3 months (P < 0.001 for each comparison). Mean intraocular pressure before surgery was 13.8 mmHg, and none of the patients developed an intraocular pressure ≥22 mmHg at any visit. None of the patients developed any serious adverse events during the follow-up. CONCLUSION: These short-term results suggest that a single DEX injection intraoperatively after phacoemulsification could avoid an increase in CRT after cataract surgery in diabetic patients.

Diabetic retinopathy: Knowledge, awareness and practices of physicians in primary-care centers in Riyadh, Saudi Arabia.

PURPOSE: Diabetic retinopathy (DR) is a serious cause of irreversible blindness and is the most common complication of diabetes. Annual fundus examination for diabetics aids in the prevention of blindness and allows intervening at a timely manner. As primary care physicians (PCP) are the main providers for diabetic care in Saudi Arabia, we aim to evaluate the current knowledge and awareness, and to assess practices among PCP regarding DR. METHODS: We conducted a cross-sectional study covering 46 randomly selected primary-care centers in Riyadh during October 2015. A Self-administered questionnaire was distributed to PCP containing 3 sections. The first section covered participants' demographics and professional background. The second section contained multiple-choice questions on knowledge related to diabetes and DR. The third section was to assess physicians' practices. RESULTS: A total of 216 PCPs completed the questionnaire. The mean overall knowledge score was 57 ± 14 out of 100. There was a significant difference in knowledge score between physicians who had obtained a subspecialty degree in family medicine compared to others (59 ± 14, 53.3 ± 14 respectively; P = 0.003). Only 19% of PCPs were aware of anti-vascular endothelial growth factor (VEGF) injections as a modality of treatment. A defect was found in the screening and follow-up of type 1 diabetics, and only 24% of physicians correctly referred patients with type 1 diabetes to an ophthalmologist. CONCLUSION: Our study uncovered areas of defects in knowledge among PCP regarding DR. This needs to be addressed in future seminars and workshops with an emphasis on the proper ophthalmological screening and management of diabetic patients.

Dexamethasone intravitreal implant as adjunct therapy for patients with wet age-related macular degeneration with incomplete response to ranibizumab.

PURPOSE: To evaluate the visual and anatomical outcomes of dexamethasone intravitreal implant (DXI; 700 µg, Ozurdex; Allergan, Irvine, California, USA) as adjunctive therapy for patients with refractory wet age-related macular degeneration (AMD). METHODS: Retrospective review of the medical records of seven patients (seven eyes) who initially responded well to intravitreal ranibizumab but subsequently developed persistent intra/sub-retinal fluid (IRF/SRF) and underwent a single injection of DXI, between May 2012 and May 2013. Two weeks after DXI, the patients continued with their monthly ranibizumab injections. Best corrected visual acuity (BCVA) logarithm of the minimum angle of resolution (logMAR) and central retinal thickness (CRT) were recorded at baseline, 2 weeks, 6 weeks, 3 months and 6 months after DXI injection. Complications were recorded too. RESULTS: All patients had at least 24 months of ranibizumab treatment. Mean age was 81.5±5.8 years. At baseline, mean BCVA was 0.53±0.13 logMAR (20/70 Snellen) and mean CRT was 273.14±50.94 µm. BCVA did not change significantly after DXI over the follow-up period. However, all eyes had lost fewer than 0.3 logMAR units. Complete resolution of the persistent IRF/SRF was achieved in five eyes (71.4%) at 6 weeks, and remained stable at 3 months. Two weeks after DXI injection, the mean CRT diminished compared with baseline (248.28±31.8 µm; p=0.03) and the greatest reduction was observed at 3 months after DXI injection (241.5±36.6 µm; p=0.04). Progression of lens opacity was detected in one case (50% of phakic eyes). Retreatment with DXI was performed in two eyes. CONCLUSIONS: DXI appears to be effective in vision stabilisation, decreasing IRF/SRF and improvement of CRT in eyes with refractory wet AMD.