Clinical Findings Predicting Posttraumatic Endophthalmitis after Repair of Open Globe Injuries.

BACKGROUND: To evaluate risk factors for developing endophthalmitis after repair of open globe injuries. METHODS: Retrospective chart analysis of 1303 patients from May 1996 till December 2019. RESULTS: All patients received prophylactic intravenous broad-spectrum antibiotics for 5-7 days. Endophthalmitis was clinically suspected in 37 (2.8%) eyes and was culture proven in 14 of these eyes (1.1%). Univariate analysis identified poor initial visual acuity at presentation, rural setting of injury, contaminated wound and lens injury as significant predictors for the development of clinically suspected endophthalmitis. Intravitreal antibiotics at the time of primary repair in eyes with high-risk characteristics decreased risk of developing endophthalmitis (OR: 2.28;95% CI,1.07-4.86; p = .033). CONCLUSIONS: Poor initial visual acuity, rural setting of injury, contaminated wound, and lens injury increased risk of suspected posttraumatic endophthalmitis. Prophylactic intravitreal antibiotics at the time of primary repair in eyes with high-risk characteristics reduced the risk of posttraumatic endophthalmitis.

Herpes Simplex Virus Keratitis Reactivation after SARS-CoV-2 BNT162b2 mRNA Vaccination: A Report of Two Cases.

PURPOSE: To report two cases of herpes simplex virus keratitis reactivation following Pfizer-BioNTech COVID-19 (BNT162b2) mRNA vaccination. METHODS: Two patients (one male, age 42 years, and one female, age 29 years) who are known to have herpetic keratitis presented to our emergency room in a time frame between 4 days and 4 weeks of receiving the vaccine. One patient presented with necrotizing stromal keratitis; the other presented with endotheliitis and epithelial keratitis. PCR for herpes simplex virus (HSV) was obtained from the two patients, and all cases received systemic acyclovir. RESULTS: PCR for HSV came positive in both cases. Patients responded well to the provided treatment. CONCLUSION: Ocular herpetic infection may be activated by COVID-19 (BNT162b2) mRNA vaccine. Treating physician should be alert to such associations, and patients should be followed closely. No direct causality has been proven, but further reporting and investigating similar conditions is recommended.

Prophylactic intravitreal antibiotics reduce the risk of post-traumatic endophthalmitis after repair of open globe injuries.

PURPOSE: To investigate efficacy of prophylactic intravitreal antibiotics in reducing incidence of endophthalmitis after repair of open globe injuries. At King Abdulaziz University Hospital, a standard protocol of intravenous vancomycin and ceftazidime was used in all cases. METHODS: Charts of 353 patients who presented between January 2010 and January 2014 with open globe injury were retrospectively reviewed. In addition, the standard protocol in this cohort included prophylactic intravitreal antibiotics in high-risk cases at time of primary repair. High-risk cases were identified based on the presence of one or more of the following risk factors: dirty wound, retained intra-ocular foreign body (IOFB), rural setting, delayed primary repair of >24 hr and ruptured lens capsule. Rate of endophthalmitis in this recent cohort was compared with that of a previous cohort admitted for primary repair between May 1996 and May 2008 (641 patients). In the previous cohort, protocol did not include prophylactic intravitreal antibiotics. RESULTS: Rates of clinically suspected endophthalmitis and culture-positive endophthalmitis were higher in previous cohort (24 of 641 eyes; 3.7% and 12 of 641 eyes; 1.9%, respectively) compared to recent cohort (six of 353 eyes; 1.7% and two of 353 eyes; 0.6%, respectively). In high-risk groups, rates of suspected endophthalmitis and culture-positive endophthalmitis were higher in previous cohort (19 of 345 eyes; 5.5% and 12 of 345 eyes; 3.5%, respectively) compared to the recent cohort (five of 200 eyes; 2.5% and two of 200 eyes; 1.0%, respectively). CONCLUSION: Prophylactic intravitreal antibiotics reduce risk of endophthalmitis after repair of open globe injuries.

Glaucoma After Open-globe Injury at a Tertiary Care University Hospital: Cumulative Causes and Management.

PURPOSE: To investigate causes and treatment modalities of traumatic glaucoma after open-globe injury (OGI). MATERIALS AND METHODS: The medical records of all patients with postrepair follow-up of OGI at a tertiary care university hospital from January 1996 to December 2010 were reviewed. These patients had persistent elevated intraocular pressure (IOP) of >21 mm Hg at 2 consecutive visits, with or without optic disc damages. RESULTS: Over the 14-year study period, 41 eyes of 41 patients with repaired OGI that developed glaucoma were identified. In the early stage (within 1 mo), high IOP levels occurred owing to the presence of unremoved lens particles in 11 patients (26.8%), inflammation in 6 patients (14.6%), and hyphema in 3 patients (7.3%). In the intermediate stage (2 to 6 mo), the IOP increased owing to the presence of synechial angle closure in 9 patients (21.9%) and ghost cells in 3 patients (7.3%). In the late stage (>6 mo), the IOP rose owing to the presence of unremoved lens particles in 2 patients (4.8%), angle recession in 4 patients (9.7%), and synechial angle closure in 3 patients (7.3%). Surgical interventions included trabeculectomy in 9 eyes (22%), lens aspiration in 9 eyes (22%), cyclophotocoagulation (CPC) in 5 eyes (12.2%), anterior chamber washout in 3 eyes (7.3%), and tube surgery in 2 eyes (4.9%). CONCLUSIONS: Traumatic glaucoma is not uncommon long-term complication after OGI. It is important to inspect the association between the initial cause and achieving a successful treatment. Surgical intervention may be crucial in the majority of cases.

Patterns of Uveitis in a University-based Tertiary Referral Center in Riyadh, Saudi Arabia.

PURPOSE: To investigate the referral patterns and diagnosis of uveitis in a university-based tertiary referral center in Riyadh, Saudi Arabia. METHODS: We retrospectively reviewed the medical records of 642 patients (1220 eyes). RESULTS: There were 295 (46%) males and 347 (54%) female patients, with a mean age of 36.4 ± 16.1 years at presentation. Panuveitis was most common (47.1%), followed by anterior uveitis (36.8%), posterior uveitis (10.7%), and intermediate uveitis (5.4%). Nongranulomatous (85.2%) and noninfectious (69.3%) were the most frequent types of uveitis. The most identifiable specific diagnoses were Vogt-Koyanagi-Harada (VKH) disease (19.6%), presumed tuberculous uveitis (PTU) (17.8%), Behçet disease (BD) (8.4%), and toxoplasmosis (6.9%). After a mean follow-up period of 31.3 ± 31.5 months, 73.5% of the eyes achieved visual acuity of 20/40 or better. CONCLUSIONS: The most common anatomic diagnosis was panuveitis. VKH disease, PTU, BD, and toxoplasmosis are the most frequently diagnosed entities.

Cataract surgery under systemic infliximab therapy in patients with refractory uveitis associated with Behcet disease.

BACKGROUND AND OBJECTIVES: This study is to evaluate the outcome of cataract surgery in patients with refractory uveitis associated with Behçet disease (BD) treated with infliximab. DESIGN AND SETTINGS: A retrospective study in a university-based tertiary referral center in the period between July 2003 and November 2011. METHODS: This is a retrospective study of patients with refractory uveitis associated with BD who underwent phacoemulsification cataract surgery under systemic infliximab therapy between July 2003 and November 2011 at King Abdulaziz University Hospital, Riyadh, Saudi Arabia. RESULTS: Six patients (9 eyes), 5 of which were male and 1 female, were identified in this study. The mean (SD) age and follow-up period were 26.2 (6.6) years (range, 16-36 years) and 51.6 (28.8) months (range, 12.84 months), respectively. All the patients underwent phacoemulsification with intraocular lens implantation. Postoperatively, visual acuity improved in all eyes and was 20/40 or better in 7 eyes (77.8%). In the immediate postoperative period, anterior chamber inflammation ranged from 2+ to 3+ cells. None of the patients developed inflammation relapse postoperatively. The most common postoperative complication was posterior capsular opacification in 5 eyes (55%), 4 of which were managed with neodymium:yttrium-aluminum garnet laser capsulotomy. Three eyes had glaucoma, 2 of which underwent successful glaucoma surgery and one was managed with topical antiglaucoma medications. CONCLUSION: In patients with refractory uveitis associated with BD who are treated with infliximab, cataract surgery is safe and has a good prognosis.

Glaucoma after open globe injury at a tertiary care university hospital in Central Saudi Arabia. Cumulative incidence and risk factors.

OBJECTIVE: To investigate the incidence and risk factors of glaucoma after open globe injury (OGI). METHODS: The medical records of all patients admitted with the diagnosis of OGI at the Department of Ophthalmology, King Abdulaziz University Hospital, Riyadh, Kingdom of Saudi Arabia and had undergone primary repair from January 1996 to December 2011 were retrospectively reviewed. RESULTS: For the 15-year study period, 775 patients who underwent repair of an OGI were identified. The overall risk of post-traumatic glaucoma was 5.3% (41/775) with a mean +/- SD follow-up period of 12+/-6.5 months. Univariate analysis revealed that Zone II injury (p=0.027), penetrating ocular injury (p=0.0008), lens injury (p=0.011), vitreous hemorrhage (p=0.002), and presence of intraocular foreign body (p<0.0001) were significantly associated with glaucoma. Age of more than 18 years was critical (p=0.054). Following logistic regression, penetrating ocular injury (p=0.019), lens injury (p=0.002), and vitreous hemorrhage were significant (p=0.037). CONCLUSION: Glaucoma after OGI is not uncommon. Zone II injury, penetrating ocular injury, lens injury, presence of vitreous hemorrhage, and presence of an intraocular foreign body were significant risk factors for developing post-traumatic glaucoma.

Prognostic factors for clinical outcomes in patients with Vogt-Koyanagi-Harada disease treated with high-dose corticosteroids.

PURPOSE: To determine prognostic factors in patients with Vogt-Koyanagi-Harada (VKH) disease who were treated with high-dose corticosteroids. METHODS: Retrospective analysis of 87 patients (174 eyes). RESULTS: At presentation, there were 53 patients with initial-onset acute VKH disease and 34 patients with chronic recurrent VKH disease. Chronic recurrent presentation was significantly associated with more severe anterior segment inflammation at presentation as indicated by presence of mutton-fat keratic precipitates, anterior chamber reaction ≥2+, iris nodules and posterior synechiae (p < 0.001 for all comparisons), less exudative retinal detachment at presentation (p < 0.001), more complications during the follow-up period (p < 0.001) and a worse visual outcome (p < 0.001). The use of immunomodulatory therapy (cyclosporine and mycophenolate mofetil) as first-line therapy significantly reduced the development of complications in the whole study group (p = 0.006) and in initial-onset acute group (p = 0.024) and improved visual outcome in the whole study group (p = 0.004) and in chronic recurrent group (p = 0.024). In the whole study group, final visual acuity of 20/20 was significantly associated with good initial visual acuity of >20/200 [odds ratio = 4.25; 95% Confidence interval (CI) = 1.53-11.89] and age older than 16 years was significantly associated with the development of complications (odds ratio = 3.15; 95% CI = 1.04-9.48). CONCLUSIONS: Chronic recurrent VKH disease is significantly associated with more severe anterior segment inflammation and less exudative retinal detachment at presentation, more ocular complications and a worse visual outcome than initial-onset acute VKH disease. Use of immunomodulatory therapy significantly improved the clinical outcomes.

Solitary presumed choroidal tuberculomas masquerading as choroidal tumors.

The ocular involvement of tuberculosis is not uncommon but diverse. Rarely, patients initially present with ocular signs that simulate intraocular malignancy. We report 3 cases of isolated presumed choroidal tuberculoma masquerading as intraocular tumor. Two patients had no systemic evidence of tuberculosis with strongly positive purified protein derivative skin test and one patient had evidence of inactive old pulmonary tuberculosis demonstrated by chest computed tomography. Antituberculous regimen including isoniazid 5 mg/kg/day, rifampicin 600 mg/day, ethambutol 15 mg/kg/day, and pyrazinamide 30 mg/kg/day were employed in all cases for 9 months. In addition, oral prednisone 1 mg/kg/day has been given until clinical response was seen, then slowly tapered over 4 months until discontinued. All cases responded well to treatment without complications. Ocular tuberculosis may show challenging clinical presentations, and proper diagnosis and treatment can save the patient's eye and even life.

The outcomes of mycophenolate mofetil therapy combined with systemic corticosteroids in acute uveitis associated with Vogt-Koyanagi-Harada disease.

PURPOSE: To study the effectiveness of mycophenolate mofetil (MMF) as first-line therapy combined with systemic corticosteroids in acute uveitis associated with Vogt-Koyanagi-Harada (VKH) disease. The outcomes in this group were compared with those of another group of patients with VKH disease who were treated with corticosteroid monotherapy or with delayed addition of immunomodulatory therapy. METHODS: This prospective study included 19 patients (38 eyes) diagnosed with acute uveitis associated with VKH disease. RESULTS: The mean follow-up period was 27.0 ± 11.1 months (range 16-54 months). Corticosteroid-sparing effect was achieved in all patients. The mean interval between starting treatment and tapering prednisone to 10 mg or less daily was 5.1 ± 1.2 months (range 3-7 months). Ten (53%) patients discontinued treatment without relapse of inflammation. The mean time observed of treatment was 17.3 ± 11.9 months (range 3-41.5 months). Visual acuity of 20/20 was achieved by 38% of the eyes in the corticosteroid group and by 74% in the corticosteroid + MMF group (p < 0.001). Recurrent inflammation of ≥3 times was reduced significantly (p = 0.0383) in the corticosteroid + MMF group (3%) as compared to corticosteroid group (18%). Development of all complications was significantly higher in the corticosteroid group (43%) compared with the corticosteroid + MMF group (8%) (p < 0.001). None of the eyes in the corticosteroid + MMF group developed 'sunset glow fundus'. CONCLUSIONS: Addition of MMF as first-line therapy to corticosteroids in patients with acute uveitis associated with VKH disease leads to significant reduction in recurrences of uveitis and development of late complications and significantly improves visual outcome.

Retinal functional changes measured by microperimetry after immunosuppressive therapy in patients with Vogt-Koyanagi-Harada disease.

PURPOSE: To evaluate the effect of immunosuppressive therapy on best-corrected visual acuity (BCVA), fixation stability, and central retinal sensitivity in patients with Vogt-Koyanagi-Harada (VKH) disease in the acute uveitic phase. Methods. In this prospective study, 14 patients (28 eyes) were evaluated. Best-corrected visual acuity and MP-1 microperimetric evaluation of retinal sensitivity in the central 12 degrees and fixation stability were assessed at baseline and at 1, 3, 6, 9, and 12 months after treatment. Results. At baseline, logarithm of the minimum angle of resolution (logMAR) BCVA, fixation stability, and mean retinal sensitivity levels were 0.685 ± 0.6 (Snellen equivalent, 20/100), 61.2% ± 29.0%, and 2.75 ± 3.8 dB, respectively. At 3 months, logMAR BCVA (0.11 ± 0.2, Snellen equivalent 20/25) and fixation stability (86.4% ± 13.4%) were almost maximum (p<0.001 for both comparisons), and thereafter remained almost unchanged. Mean retinal sensitivity continued to improve up to 12 months (12.0 ± 2.3 dB, p<0.001); however, it was still significantly decreased. There were significant correlations between logMAR BCVA and mean retinal sensitivity at all time points. The percentages of BCVA improvement were significantly higher than the percentages of mean retinal sensitivity improvement at all time points (p<0.001 for all comparisons). Conclusions. Compared with microperimetry, BCVA significantly underestimates macular dysfunction in VKH disease.

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.

Advances in the treatment of diabetic retinopathy.

Diabetic retinopathy, the most common long-term complication of diabetes mellitus, remains one of the leading causes of blindness worldwide. Strict metabolic control, tight blood pressure control, laser photocoagulation, and vitrectomy remain the standard care for diabetic retinopathy. Focal/grid photocoagulation is a better treatment than intravitreal triamcinolone acetonide in eyes with diabetic macular edema and should be considered as the first-line therapeutic option. The current evidence suggests that intravitreal triamcinolone acetonide or anti-vascular endothelial growth factor agents result in a temporary improvement of visual acuity and a short-term reduction in central macular thickness in patients with refractory diabetic macular edema and are an effective adjunctive treatments to laser photocoagulation or vitrectomy. However, triamcinolone is associated with risks of elevated intraocular pressure and cataract. Vitrectomy with the removal of the posterior hyaloid without internal limiting membrane peeling seems to be effective in eyes with persistent diffuse diabetic macular edema, particularly in eyes with associated vitreomacular traction. Emerging therapies include islet cell transplantation, fenofibrate, ruboxistaurin, pharmacologic vitreolysis, rennin-angiotensin system blockers, and peroxisome proliferator-activated receptor gamma agonists.

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.

Patterns of uveitis in patients admitted to a University Hospital in Riyadh, Saudi Arabia.

PURPOSE: To analyze clinical patterns, causes, and systemic disease associations among patients with uveitis admitted to King Abdulaziz University Hospital. METHODS: The authors retrospectively reviewed the medical records of 351 patients (600 eyes). RESULTS: The study subjects consisted of 183 (52.1%) males and 168 (47.9%) females, with a mean age of 39.9 ± 14.2 years at presentation. The most common anatomic diagnosis was panuveitis (68.6%), followed by posterior uveitis (12.7%), anterior uveitis (12.7%), and intermediate uveitis (6.0%). The most common identifiable specific diagnoses were presumed tuberculous uveitis (PTU) (28.2%), Vogt-Koyanagi-Harada (VKH) disease (19.4%), Behçet disease (BD) (12.5%), and toxoplasmosis (8.2%). After a mean follow-up period of 29.5 ± 22.1 months, 63.5% of the eyes achieved visual acuity of 20/40 or better. Eyes from patients with PTU had the worst final visual outcome. CONCLUSIONS: The most common anatomic diagnosis was panuveitis. PTU, VKH disease, BD, and toxoplasmosis were the most frequent specific diagnoses.

Central posterior capsule pigmentation in a patient with pigment dispersion and previous ocular trauma: a case report.

We report a 55-year-old man with unusually dense, unilateral central posterior capsule pigmentation associated with the characteristic clinical features of pigment dispersion syndrome, including a Krukenberg's spindle and dense trabecular pigmentation in both eyes. A history of an old blunt ocular trauma probably caused separation of the anterior hyaloid from the back of the lens, thereby creating an avenue by which pigment could reach the potential space of Berger's from the posterior chamber.

Anti-tuberculous therapy combined with systemic corticosteroids improves retinal sensitivity in patients with active presumed tuberculous choroiditis.

To investigate the efficacy of anti-tuberculous therapy and systemic corticosteroids in patients suffering from active presumed tuberculous choroiditis by the assessment of central retinal sensitivity and fixation characteristics. Six patients (six eyes) with active presumed tuberculous choroiditis were treated with anti-tuberculous therapy and systemic corticosteroids. Mean central retinal sensitivities and fixation stability and location were investigated with MP-1 microperimetry before and after treatment. After a mean follow-up of 11.33 ± 7.53 months (range 6-24 months), all eyes showed resolution of inflammation, with no recurrences, associated with a significant improvement in visual acuity (P = 0.003). At the baseline, mean central retinal sensitivities were 2.03 ± 2.46 dB (range 0.0-6.6 dB). Fixation was stable and predominantly central in three eyes, and unstable and predominantly eccentric in three eyes. After treatment at a mean of 9.33 ± 6.56 months (range 4-20 months), mean central retinal sensitivities improved to 9.65 ± 5.35 dB (range 2.4-15.2 dB) (P = 0.004) and fixation became predominantly central and stable in all eyes. Anti-tuberculous therapy combined with systemic corticosteroids improves central retinal sensitivity and fixation characteristics in patients with presumed tuberculous choroiditis.