Saudi Arabian retinopathy of prematurity national telemedicine program: Achievements and challenges.

The Saudi Arabian Retinopathy of Prematurity National Telemedicine programme (SAROP) is a product of the National Committee for Retinopathy of Prematurity (ROP). The program includes ROP telescreening, diagnosis, and management of cases requiring treatment. Digital retinal images and filled ROP software requests were uploaded from 20 level-3 neonatal intensive care units (NICU) in the Kingdom of Saudi Arabia (KSA) to the King Khaled Eye Specialist Hospital server and the ROP telemedicine website. The data were accessed and reported by qualified retinal and pediatric ophthalmologists. Currently, retinal wide-angle digital cameras are available in 20 of the 31 level-3 NICUs of the Ministry of Health, Kingdom of KSA. This telemedicine approach is practical and effective in detecting and managing ROP cases. In the first 2.5 years, encouraging results were noticed with no unfavorable outcomes in the participating NICUs. Technical challenges were resolved promptly to ensure that the program ran smoothly. Therefore, this ideal state-of-the-art ROP telemedicine program could be also applied to similar and neighboring countries.

Managing Challenges of Phacoemulsification in Vitrectomized Eyes: A New Technique.

AIM: This study aimed to describe a novel approach to manage the challenges of phacoemulsification in vitrectomized eyes. METHODS: Intraoperative titrated intravitreal injection of balanced salt solution (BSS) through pars plana was done using a 30G needle hooked to a 1 cc syringe to build up the vitreous pressure. RESULTS: Five eyes of five patients who had previous vitrectomy were given intraoperative injection. This led to the prevention of lens-iris diaphragm retropulsion and routine completion of phacoemulsification. The preoperative visual acuity was < 6/60 in all patients. The postoperative visual acuity was 6/9 or better in all patients, except in one patient which was 6/60, which is explained by diabetic ischemic maculopathy. Neither injection-related intraoperative nor postoperative complications were noted. CONCLUSION: Challenges of phacoemulsification in vitrectomized eyes can be prevented by a simple titrated intraoperative injection of BSS intravitreally through pars plana.

Practical guidelines for screening and treatment of retinopathy of prematurity in Saudi Arabia.

Retinopathy of Prematurity (ROP) is one of the leading causes of bilateral blindness in childhood. Early detection and effective treatment can prevent blindness. Efficient and timely screening examination of the retina by an experienced ophthalmologist who deals with preterm neonates with ROP is the mainstay in the management of this disease. All neonatologists and pediatricians who care for these at-risk preterm neonates should also be aware of this timing. This practical guideline intends to provide guidance to ophthalmologists, neonatologists and allied health care professionals in Saudi Arabia on current indications for screening and management of retinopathy of prematurity to prevent or minimize subsequent complications. This practical guideline was led by the National Eye Health Program (NEHP) and Neonatology Services Improvement Program at Ministry of Health (MOH), furthermore it has been solicited and endorsed from both Saudi Ophthalmological Society (SOS) and Saudi Neonatology Society (SNS).

Outcomes of Retreatment after Aborted Laser In Situ Keratomileusis due to Flap Complications.

PURPOSE: To determine the refractive outcomes and complications of retreatment after aborted primary laser in situ keratomileusis (LASIK) due to flap complications. MATERIALS AND METHODS: This retrospective study evaluated 50 retreated eyes that had flap complications during primary LASIK at the Eye Consultants Center in Riyadh, Saudi Arabia. Data were analyzed for patients with at least 3 months follow-up post retreatment. RESULTS: Thirty-three eyes of 31 consecutive patients with 3 months follow-up or later post retreatment were included. The primary LASIK was aborted due to incomplete flaps in 22 eyes (66.7%), buttonhole flaps in 7 eyes (21.2%), free partial flaps in 3 eyes (9.1%), and a free complete flap in 1 eye (3.0%). Twenty-two eyes (66.7%) were retreated with LASIK, and 11 eyes (33.3%) were retreated with surface ablation. The mean spherical equivalent (SE) was -0.23 ± 0.72 D, the mean astigmatism was -0.65 ± 0.89 D, and the mean loss of the best corrected visual acuity (BCVA) was 0.78 lines at the final postoperative visit. At the last postoperative visit, 20/30 or better BCVA was achieved in 90.1% of eyes that underwent retreatment with LASIK and in 91% of eyes that were retreated with surface ablation. There was no statistical difference in postoperative SE between eyes retreated with LASIK and eyes retreated with surface ablation (P = 0.610). There was no statistical difference in postoperative BCVA between eyes retreated with LASIK and those retreated with surface ablation (P = 0.756). There were no intraoperative complications and no eyes required a second retreatment. CONCLUSION: Creation of a flap after a previous intraoperative flap complication was not associated with any complications. The refractive outcomes of retreatment with LASIK or surface ablation were comparable and reasonably favorable.

Intraoperative flap complications in laser in situ keratomileusis with two types of microkeratomes.

PURPOSE: To determine the incidence and types of intraoperative flap complications in laser in situ keratomileusis (LASIK) encountered with the Hansatome microkeratome and the Moria microkeratome. METHODS: In this retrospective case series, all patients with intraoperative flap complications who were treated between June 1999 and July 2008 at the Eye Consultants Center in Riyadh, Saudi Arabia, were identified and reviewed. RESULTS: Of the 4352 subjects who underwent bilateral primary LASIK procedure, intraoperative microkeratome complications were detected in 89 eyes of 83 patients. The overall incidence of flap complications was 89/8704 (1.00%): incomplete flaps occurred in 53 eyes (0.60%), followed by buttonhole flaps in 17 eyes (0.19%), free complete flaps in 10 eyes (0.11%), free partial flaps in 6 eyes (0.07%), sluffed epithelium in 2 eyes (0.023%), and a splitted flap (vertical flap cut) in 1 eye (0.01%). The incidence rates of intraoperative flap complications with the Hansatome microkeratome and the Moria microkeratome were 1.21% (41/3378) and 0.90% (48/5326), respectively (P = 0.19). There was a statistically significant difference between the two microkeratomes with regard to the incidence of buttonhole flaps: 0.33% (11/3378) for the Hansatome microkeratome versus 0.11% (6/5326) for the Moria microkeratome (P = 0.04). CONCLUSION: Generally, the incidence rates of intraoperative flap complications with the Hansatome microkeratome and the Moria microkeratome were similar. However, buttonhole flaps occurred more often with the Hansatome microkeratome (a type of microkeratome that produces larger flaps). The commonest complication encountered was the incomplete flap, followed by the buttonhole flap and free flap.

Comparison of central corneal thickness measurements using Pentacam and ultrasonic pachymetry in post-LASIK eyes for myopia.

PURPOSE: To compare central corneal thickness (CCT) measurements obtained using the Pentacam Scheimpflug system with those obtained using DGH ultrasound pachymetry (UP) in post-laser in situ keratomileusis (LASIK) eyes for myopia. METHODS: In a prospective study, measurement agreement was assessed in 143 eyes of 72 post-LASIK patients using both the Pentacam and UP at the Eye Consultants Center in Riyadh, Saudi Arabia. RESULTS: The mean CCT was 522 +/- 42.2 microm with the Oculus Pentacam and 516.2 +/- 40.6 microm with UP. The Bland-Altman plot showed that the mean +/- SD for the differences between the 2 devices was 5.8 +/- 13.6 microm, with 95% confidence interval limits ranging from -20.9 microm to 32.6 microm. A test of statistical significance indicated that the mean differences of 5.8 +/- 13.6 microm differed significantly from zero (p<0.001; Wilcoxon signed-rank test), thus indicating that the Pentacam measurements tended to overestimate CCT compared with UP. Analysis of regression showed a high correlation between the values obtained with both devices (r=0.947, p<0.001). CONCLUSIONS: In post-LASIK myopic eyes, although a high correlation has been shown between Pentacam and UP measurements, Pentacam tends to overestimate CCT compared to UP. Pentacam probably cannot be used interchangeably with UP in post-LASIK eyes for myopia.

Incidence, management, and visual outcomes of buttonholed laser in situ keratomileusis flaps.

PURPOSE: To describe the incidence, management, and visual outcomes of buttonholed laser in situ keratomileusis (LASIK) flaps. SETTING: Private practice, Riyadh, Saudi Arabia. METHODS: This retrospective review identified eyes that developed buttonholed flaps during LASIK. Preoperative, intraoperative, and postoperative data were obtained to identify factors predictive of this complication. RESULTS: Of 4250 primary LASIK procedures, 17 eyes (0.4%) with buttonholed flaps were identified. Buttonholes occurred with the Hansatome microkeratome in 64.7% of eyes and with the Moria microkeratome in 35.3% of eyes, the incidence of buttonholed flaps was 0.62% and 0.19%, respectively (P = .03). Laser ablation was performed at the same time as buttonhole formation in 8 eyes (47.1%) and was aborted in the other eyes. Retreatment was performed in 10 eyes (58.8%); of retreated eyes, 6 had repeat LASIK and 3 had surface ablation. The final spherical equivalent refraction was -0.38 diopter +/- 0.79 (SD). Two eyes had a final loss of more than 2 lines of best corrected visual acuity (BCVA). The mean loss of BCVA lines was 0.72 in eyes that had complete LASIK, 0.62 in eyes that had aborted LASIK followed by retreatment with repeat LASIK, and 0.80 in eyes that had aborted LASIK followed by retreatment with surface ablation. CONCLUSIONS: Buttonholed flaps occurred more frequently in the second of 2 consecutively treated eyes. Microkeratomes that produce a larger diameter flap were more likely to produce flap buttonholes. The least loss of BCVA was achieved when LASIK was aborted and then repeated after refractive stability.

The relationship between central corneal thickness and degree of myopia among Saudi adults.

PURPOSE: To determine the relationship between central corneal thickness (CCT) and myopia among Saudi adults. METHODS: In a prospective study, the CCT of 982 myopic eyes and 158 emmetropic eyes as a control group was measured using ultrasound pachymetry at the Eye Consultants Center, Riyadh, Saudi Arabia. RESULT: The mean myopic spherical equivalent (SE) was -3.7 +/- 2.12 D, range -0.25 to -15.0 D.The mean CCT of the myopic group was 543.8 +/- 35.40 microm, while for the emmetropic group it was 545.7 +/- 27.6 microm. The difference in mean CCT between the two groups was statistically insignificant (P = 0.5). There was no correlation between CCT and the degree of myopic spherical equivalent (r = -0.014, P = 0.939). CONCLUSION: This clinical study showed that there was no difference in CCT between emmetropic and myopic eyes. CCT did not correlate with the degree of myopia. It seems that the central cornea is not significantly involved in the process of myopic progression.

Comparison between central corneal thickness measurements by oculus pentacam and ultrasonic pachymetry.

PURPOSE: To compare the accuracy of central corneal thickness (CCT) measurements by the oculus pentacam scheimpflug system, with those obtained with the DGH ultrasound pachymeter (UP) and to assess the agreement between the two devices. METHODS: In a prospective study, measurement agreement was assessed in 984 eyes of 492 healthy subjects using both oculus pentacam and ultrasonic pachymetry at the Eye Consultants Center, Riyadh, Saudi Arabia. RESULT: In the measurement agreement experiment, the mean CCT was 552.4 +/- 37.0 microm with oculus pentacam and 544.1 +/- 35.4 microm with ultrasonic pachymetry. Regression analysis showed a high correlation between the values obtained with both devices (r = 0.912, P < 0.001). Compared with UP, pentacam overestimated the CCT by a mean of 8.2 microm as demonstrated in a Bland-Altman plot. CONCLUSION: the CCT measurements by the pentacam and UP are highly correlated. The pentacam agrees well with UP and is a reliable alternative to UP in CCT measurements.

Risk factors for acute retinopathy of prematurity.

We prospectively studied the risk factors and the incidence of retinopathy of prematurity (ROP) in 195 consecutive preterm infants. Birth weight and duration of mechanical ventilation were the only factors that were significantly associated with the incidence of ROP. While indomethacin increases the risk of developing ROP, maternal antenatal steroids have a protective effect against the development of severe stages of ROP. The presence of intraventricular hemorrhage increases the risk of severe ROP.

Risk factors for acute retinopathy of prematurity.

We prospectively studied the risk factors and the incidence of retinopathy of prematurity (ROP) in 195 consecutive preterm infants. Birth weight and duration of mechanical ventilation were the only factors significantly associated with the incidence of ROP. While indomethacin increases the risk of developing ROP, maternal antenatal steroids have a protective effect against the development of severe stages of ROP. The presence of intraventricular hemorrhage increases the risk of severe ROP.

Expression of angiogenic and fibrogenic factors in proliferative vitreoretinal disorders.

PURPOSE: To investigate the expression of connective tissue growth factor (CTGF) in the retina of human subjects with diabetes mellitus, and CTGF, CD105, and gelatinase B in proliferative diabetic retinopathy (PDR) and proliferative vitreoretinopathy (PVR) epiretinal membranes. METHODS: Twelve donor eyes from six subjects with diabetes mellitus, 10 eyes from five nondiabetic subjects, 14 PDR membranes, and five PVR membranes were studied by immunohistochemical techniques. In situ zymography was used to examine gelatinolytic activity in four PDR membranes. RESULTS: In nondiabetic retinas, there was no immunoreactivity for CTGF. Diabetic retinas showed immunoreactivity for CTGF in ganglion cells and microglia. Vascular endothelial cells in PDR membranes expressed CTGF, CD105, and gelatinase B in 10 (71.4%), 11 (78.6%), and 5 (35.7%) membranes, respectively. Myofibroblasts in PDR membranes expressed CTGF, and gelatinase B in 14 (100%), and 6 (42.9%) membranes, respectively. There was a significant correlation between the number of blood vessels expressing the panendothelial marker CD34 and the number of blood vessels expressing CTGF (r = 0.7884; P = 0.0008), and CD105 (r = 0.6901; P = 0.0063), and the number of myofibroblasts expressing CTGF (r = 0.5922; P = 0.0257). There was a significant correlation between the number of myofibroblasts expressing alpha-smooth muscle actin and the number of myofibroblasts expressing CTGF (r = 0.8393; P = 0.0002). In situ zymography showed the presence of gelatinolytic activity in vascular endothelial cells in PDR membranes. Myofibroblasts in PVR membranes expressed CTGF, and gelatinase B. CONCLUSIONS: These results suggest a possible role of CTGF, CD105, and gelatinase B in the pathogenesis of proliferative vitreoretinal disorders.

Retinopathy of prematurity at a University Hospital in Riyadh, Saudi Arabia.

OBJECTIVE: To prospectively study the incidence and nature of retinopathy of prematurity (ROP) at a University Hospital in Riyadh, Kingdom of Saudi Arabia. METHODS: This study was carried out the Neonatal Intensive Care Unit of King Khalid University Hospital in Riyadh, Kingdom of Saudi Arabia. One hundred and ninety-five consecutive preterm infants with a birth weight of 2000 g or less were screened for ROP. The first examination was performed at 4-7 weeks of postnatal age. RESULTS: Mean gestational age of all premature infants was 28.4 2.4 weeks (range 22-34), mean birth weight was 1103 302 g (range 520-1960), and mean duration of oxygen therapy was 24.0 32.2 days (range 0-210). Seventy-three children developed acute ROP, giving an overall incidence of 37.4%. The incidence in preterms with birth weight of <1500 g and <1250 g was 41% and 50.7%. No infants with a birth weight of >1500 g developed ROP. Nineteen of the 73 children with ROP (26% or 9.7% of all infants studied) reached threshold ROP, and needed laser treatment or cryotherapy which induced regression in all of patients. CONCLUSION: Incidence of ROP in our patients in comparable to other reports. Screening for ROP should be carried out for all preterms of <1500 g birth weight. Such screening programs will identify those requiring retinal ablative surgery in order to induce regression of the acute ROP and prevent cicatrizing sequelae with subsequent traction retinal detachment and blindness.