Corneal myxoma following micro-pulse cyclophotocoagulation in a young female: A case report.

INTRODUCTION: Corneal myxoma is a rare benign tumor that can occur in the cornea where the exact cause remains unknown. However, it is thought to be a reactive process that can be caused by corneal infections, ectasia, ocular trauma, or surgery. PRESENTATION OF CASE: In this case report, we describe a 35-year-old-woman who presented with corneal myxoma after micro-pulse cyclophotocoagulation (MPCPC). The patient presented with decreased vision due to a large pedunculated white corneal mass after being treated with MPCPC as a non-surgical management of her pre-existing glaucoma. The corneal mass was localized to the sub-epithelial space and was excised successfully by a minimal invasive procedure without recurrence over a 1-year period. DISCUSSION: Corneal myxomas are unusual benign tumors typically seen in adults as whitish gelatinous lesion. Only a few individual cases and case series have been reported in the literature. The exact pathogenesis is yet to be known. The lesion is thought to be due to an inflammatory process. We are reporting a case of corneal myxoma that has occurred after MPCPC which is a non-surgical cyclodestructive procedure. The procedure has not been mentioned previously as a risk factor for corneal myxoma. Our case is the first corneal myxoma developing after MPCPC. CONCLUSION: We report a corneal myxoma noted in a young female after a non-surgical laser procedure. Though the lesion is rare, it should be considered in physicians' differential of a corneal mass especially in the presence of chronic ocular.

Spherical equivalent pre- and post-implantable collamer lens implantation in patients with myopia, hyperopia, and stable keratoconus.

PURPOSE: Refractive errors are common in Saudi Arabia and keratorefractive surgeries are usually done to correct them. However, not all patients are fit and complications postoperatively are a concern. Implantable collamer lens (ICL) implantation can be used for patients who are not fit for keratorefractive surgeries. ICL can also be used for keratoconus. We elected to evaluate the outcomes of patients who had ICL implantation for refractive errors or keratoconus. METHODS: We retrospectively reviewed patients aged between 21 and 45 years old, who attended the anterior segment clinic at King Khaled Eye Specialist Hospital and who had spherical equivalent (SE) ranging between (+16 to -23 diopters), and had ICL implantation between February 2015 and September 2017. The SE was documented before and after the surgery. Depending on the SE, patients were divided into two groups (myopia and hyperopia). Statistical analysis was done to evaluate the change in mean SE before and after surgery for patients. RESULTS: We identified 169 eyes and 155 (92%) were myopic before the surgery. Before surgery, the mean SE was -8.6 and the standard deviation (SD) was 4.4. Only 14 eyes (8%) were hyperopic before the surgery with a mean SE of +5.5 and SD of 4.8. The difference in the mean of SE between after and before the surgery for myopic eyes was statistically significant (mean difference: 7.8, SD: 5, P < 0.0001). The difference in the mean of SE between post- and pre-operatively was also significant for hyperopic eyes (mean difference: -6.1, SD: 5.2, P = 0.0007). In 32 eyes with keratoconus, the mean SE before surgery was -7.9 with an SD of 4.1. For the keratoconus eyes, the mean difference of SE between after and before surgery was statistically significant as the mean difference in SE was 7.2 with an SD of 4.6 (P < 0.0001). CONCLUSION: The effect of ICL implantation was significant in improving the SE for myopic, hyperopic, and keratoconus eyes.

Recurrent and refractory corneal perforation secondary to rheumatoid arthritis treated with infliximab.

Rheumatoid arthritis (RA) can affects many organs including the eyes. Corneal perforation in the form of peripheral ulcerative keratopathy can be debilitating and difficult to manage. A 48-year-old female with known RA presented with sudden loss of vision in her left eye, she was diagnosed with left corneal perforation secondary to severe dry eye. Penetrating keratoplasty (PKP) and punctum occlusion were done. Amniotic membrane transplant (AMT) was done 1 month later due to nonhealing epithelial defect. Her RA was clinically inactive, and no changes in her current medications were made. However, 4 months later, she presented with a second corneal perforation with melting. She had another PKP and AMT with permanent temporal tarsorrhaphy. Cyclosporine 100 mg P. O. twice daily was added, but after 5 months, she presented again with a third left corneal perforation with melting. Again, PKP and AMT with tarsorrhaphy were done, and she was started on infliximab. Since then, she had a stable graft with no further corneal perforations. In summary, patients with RA can have corneal perforations even if other signs of RA are absent. If the systemic treatment that is used to treat RA fails, one should consider using other classes of drugs, such as monoclonal antibodies (e.g., rituximab), tumor necrosis factor alpha blockers (such as infliximab or adalimumab), interleukin (IL)-1 receptor antagonists (e.g., anakinra), or IL-6 receptor antagonist (e.g., tocilizumab).

Supernumerary lacrimal puncta: Case series.

Supernumerary lacrimal punctum is rare, and very few cases have been reported. Most patients are asymptomatic, but in some excessive tearing could be a symptom. In addition, obstruction of the canaliculi causing canaliculitis has been reported. We describe four cases in detail with their presentations and diagnosis. The first patient presented with a right eye lesion and during examination, the left eye was less than mid dilated compared to that of the right eye. Further examination of the left eye revealed two left lower lid puncta. In another patient who was evaluated for diabetic retinopathy, two left lower lid puncta that shared the same canaliculus were noted. Furthermore, two lower lid puncta were found in a patient who came for cataract follow-up. Finally, in a patient who was following up in the retinal clinic, two lower lid puncta were documented. Probing to the accessory punctum showed that the canaliculus had an immediate horizontal course, unlike the rest of the puncta which showed a vertical then a horizontal course. Furthermore, in the accessory punctum, there was a soft stop, around 4 mm of the inserting probe. In summary, supernumerary lacrimal punctum is rare, and ophthalmologists need to be aware of this abnormality.

Measurement of anterior segment parameters in Saudi adults with myopia.

PURPOSE: To measure anterior segment parameters of the eye in myopic Saudi population using Pentacam. METHOD: This is retrospective cross-sectional study. Subjects were divided into three groups: low, moderate and high myopia groups. Anterior segment parameters including: central corneal thickness (CCT), thinnest corneal thickness (TCT), apex corneal thickness (Apex CT), corneal volume (CV), anterior chamber depth (ACD), anterior chamber volume (ACV) and corneal astigmatism (CA) were measured by Pentacam. RESULTS: A total of 504 eyes of 252 Saudi subjects with myopia were included in this study. The mean age ±â€¯standard deviation (SD) of subjects was 28.73 ±â€¯6.18 years. The mean CCT, TCT, Apex CT, CV, ACD, ACV and CA for all myopic subjects were 557.21 ±â€¯29.36, 554.09 ±â€¯29.28, 556.10 ±â€¯37.06, 61.30 ±â€¯3.23 µm, 3.31 ±â€¯0.27 mm, 211.15 ±â€¯34.22 mm3 and 0.89 ±â€¯0.52 D, respectively. No significant differences (P > 0.05) were found between right and left eyes in all anterior segment parameters of all myopic eyes. However, a significant difference (P < 0.05) was found in ACD between low (3.27 ±â€¯0.26 mm) and moderate (3.35 ±â€¯0.30 mm) myopic groups. Within low myopia group, significant differences (P < 0.05) were found in ACD, ACV and CA between different genders. Anterior chamber depth and ACV values were lower in females while CA was lower in males. In addition, significant positive correlation was found between ACV and ACD in all myopic groups. CONCLUSION: This study provided valuable measurements of the anterior segments parameters of the eye in myopic Saudi population. These parameters could be useful for ophthalmic practitioners in the clinic.

Prevalence of joint hypermobility in Kuwait.

AIM: To determine the prevalence of joint hypermobility (JH) among young Kuwaiti adults. METHODS: This was a cross-sectional study of 390 randomly selected healthy undergraduate university students, aged 18-29 years from the Health Sciences Centre, Kuwait University, Safat, Kuwait. Beighton score at four peripheral sites bilaterally (knees, elbows, thumbs and fifth fingers) and forward flexion of the trunk were used to evaluate joint hypermobility. Any student who met four out of the nine criteria was considered hypermobile. Joint pain was documented in all subjects through personal interview. RESULTS: A total of 390 subjects (male : female ratio 1.0 : 0.9) were assessed. Of those, 87 (22.3%) were found to have JH: 60 (29.4%) males and 27 (14.5%) females, showing a significantly higher male predominance (P < 0.001). Beighton score was inversely correlated with age (ρ = -0.15, P = 0.003). A higher incidence of finger signs was noted in comparison to elbow-knee hyperextension and hands-to-floor. Knee joint, back, neck and shoulder pains, in descending order, were the commonest type of joint complaints, although not statistically significant (P > 0.05) in subjects with and without joint hypermobility. It was also observed that the left side, at all the sites, was slightly more hypermobile in comparison to the right side in hypermobile subjects. CONCLUSIONS: The prevalence of joint hypermobility is not uncommon among young Kuwaiti adults, and was comparable to the data published in other Asian-Pacific regions. General practitioners should therefore be familiar with the condition and its clinical associations, while assessing musculoskeletal complaints.

Does occlusion therapy improve control in intermittent exotropia?

PURPOSE: The aim of this study was to evaluate the effectiveness of occlusion therapy in the control of intermittent exotropia (IXT) in children between 4 and 10 years in Saudi Arabia. This study will highlight the importance of patching IXT patients and assist to approach the proper use of occlusion therapy. METHODS: A clinical, prospective cohort pilot study was performed on 21 untreated IXT patients. Evaluation of the deviation angle, amplitudes, stereopsis and control before, during and after occlusion therapy was performed. RESULTS: Eleven percent of the subjects demonstrated a decrease in the deviation angle by 50% while 55.5% attained normal ranges for base-out fusional amplitudes and 77% attained success for the control. CONCLUSION: We suggest that alternate occlusion therapy can improve the sensory status and strengthen the fusional amplitudes but does not improve the deviation angle and therefore is useful to postpone surgery in young children and may improve surgical outcome.

Corneal spherical aberration and its impact on choosing an intraocular lens for cataract surgery.

PURPOSE: To analyze the post operative results of targeting zero spherical aberration by selecting the best-fit aspheric intraocular lens (IOL), based on preoperative corneal spherical aberration of patients with phacoemulsification surgery. SETTING: AlHokama Eye Specialist Center, Riyadh, Saudi Arabia. PERIOD: From the 1st of October 2012 until the 10th of April 2013. METHODS: Fifty-three eyes, were subjected to phacoemulsification cataract surgery and divided into two groups, 34 eyes were implanted with aspheric IOLs based on their corneal spherical aberration targeting post operative zero total spherical aberration, whereas 19 eyes were implanted with neutral aspheric IOLs regardless of their corneal spherical aberrations (CSAs). As a pre and post routine examination, patients underwent: slit lamp testing, intraocular pressure (IOP) measuring, fundus examination, best spectacle corrected visual acuity (BSCVA), manifest refraction, pupillometry, axial length, contrast sensitivity, and corneal aberration measurement using Pentacam HR (OCULUS, Germany) at the 6-mm optical zone. Post operatively, visual function questionnaire (VF-14) was asked to all patients. RESULTS: Fifty-three eyes of 45 patients, whose age ranged from 45 to 90 years old, were available for analysis, the selected group was implanted with: Tecnis ZA9003 or ZCB00 (Abbott Medical Optics) IOLs in 17 eyes with corneal spherical aberration of more than 0.27 µm, AcrySof IQ SN60WF (Alcon Laboratories Inc.) IOLs were implanted in 4 eyes with CSA = (0.2-0.27) µm, and Rayner 970C, 920H or 620H IOLs with spherical aberration (SA) = 0 in 13 eyes with CSA less than 0.20 µm. The other group of 19 eyes was implanted with aspheric IOLs that have zero spherical aberration (Rayner 970C or 920H) regardless of their CSA. Root mean square (RMS) of total corneal aberration positively correlates to the pupil diameter (P = 0.0031, r = 0.3989). A low negative correlation was found between the corneal spherical aberration of the fourth ordered (Z40) and the axial length (r = -0.2009, P = 0.1492). There was no significant difference between the selected and non-selected group in contrast sensitivity, best spectacle corrected visual acuity, and visual satisfaction (P = 0.5316, P = 0.3919, P = 0.7667). CONCLUSION: Customized selection of aspheric IOLs based on the eyes' corneal spherical aberration has no significant importance comparing their results with the non-selected group.

Corneal spherical aberration in Saudi population.

PURPOSE: To find out the mean corneal spherical aberration and its changes with age in Saudi population. SETTING: AlHokama Eye Specialist Center, Riyadh, Saudi Arabia. METHODS: Three hundred (300) eyes of 185 Saudi subjects (97 men and 88 women), whose age ranged from 15 to 85 years old, with matched refractive errors, were divided into three groups according to their age, 100 for each. All the subjects were included in measuring the spherical aberration (SA) using pentacam HR (OCULUS, Germany) at the 6-mm optical zone. RESULTS: The mean corneal spherical aberration (CSA) of the fourth order (Z4 (0)) of the whole groups was 0.252 ± 0.1154 µm. Patients from 15 to 35 years old have root mean square (RMS) of CSA of 0.2068 ± 0.07151 µm, 0.2370 ± 0.08023 µm was the RMS of CSA of the patients from 35 to 50 years old, while those from 50 to 85 years old have a CSA-RMS of 0.31511 ± 0.1503 µm (P < 0.0001). A positive correlation was found between the spherical aberration (Z4 (0)) and the progress of age (r = 0.3429, P < 0.0001). The high order aberration (HOA) presented 28.1% of the total corneal aberrations. While the fourth order corneal spherical aberration constituted 57% of the HOA and 16% of the total aberration. The pupil diameter shows a negative correlation with the increase in age (P = 0.0012). CONCLUSION: Our results showed a CSA (Z4 (0)) that is varied among the population, comparable to other studies, and significantly correlates to the progress of age.

Mutations in LRPAP1 are associated with severe myopia in humans.

Myopia is an extremely common eye disorder but the pathogenesis of its isolated form, which accounts for the overwhelming majority of cases, remains poorly understood. There is strong evidence for genetic predisposition to myopia, but determining myopia genetic risk factors has been difficult to achieve. We have identified Mendelian forms of myopia in four consanguineous families and implemented exome/autozygome analysis to identify homozygous truncating variants in LRPAP1 and CTSH as the likely causal mutations. LRPAP1 encodes a chaperone of LRP1, which is known to influence TGF-ß activity. Interestingly, we observed marked deficiency of LRP1 and upregulation of TGF-ß in cells from affected individuals, the latter being consistent with available data on the role of TGF-ß in the remodeling of the sclera in myopia and the high frequency of myopia in individuals with Marfan syndrome who characteristically have upregulation of TGF-ß signaling. CTSH, on the other hand, encodes a protease and we show that deficiency of the murine ortholog results in markedly abnormal globes consistent with the observed human phenotype. Our data highlight a role for LRPAP1 and CTSH in myopia genetics and demonstrate the power of Mendelian forms in illuminating new molecular mechanisms that may be relevant to common phenotypes.

Compliance to patching in the treatment of amblyopia.

PURPOSE: To evaluate compliance of amblyopic patients to patching, and to identify reasons of poor compliance and suggest methods to overcome the problem. METHODS: We conducted a cross-sectional, retrospective study that included 37 families with a child diagnosed with unilateral amblyopia (age range 3-16 years) and attending the Pediatrics Ophthalmology clinic at the King Abdulaziz University Hospital (a tertiary eye hospital). Data were collected through interviews and from hospital charts. In the interviews we asked questions that sought information with regard to four aspects (domains); knowledge, attitude, insight and community's effect. A score representing each domain was given to every family then we correlated these scores with family's compliance percentage. RESULTS: When correlated with compliance, the insight and attitude domains showed a statistically significant correlation; p-value 0.002 and 0.004, respectively. However, the knowledge and community's effect domains were not; p-value 0.084 and 0.114, respectively. Other qualitative factors affecting compliance were identified with open questions. Quotes from families of what they think can improve compliance are shown. CONCLUSION: To improve compliance, merely educating patients is not sufficient and more efforts should be undertaken toward ensuring true sense of the problem and its impact. Factors affecting compliance due to the physical properties in the patch itself should be addressed too (heat, irritation, poor adhesive material and design).

Diagnostic coding of abuse related fractures at two children's emergency departments.

OBJECTIVES: Pediatric fractures suspicious for abuse are often evaluated in emergency departments (ED), although corresponding diagnostic coding for possible abuse may be lacking. Thus, the primary objective of this study was to determine the proportion of fracture cases investigated in the ED for abuse that had corresponding International Classification of Diseases (ICD) codes documenting abuse suspicion. Additional objectives were to determine the proportion of these fractures with admission ICD abuse coding, and physician text diagnoses recording abuse suspicion in the ED and/or admission notes. Factors possibly associated with abuse-related ED ICD codes were also examined. METHODS: Children less than three years of age that presented primarily with a fracture to two large academic children's hospitals from 1997 to 2007 and were evaluated for suspicion of abuse by child protective services were included in this retrospective review. The main outcome measure was the proportion of the fracture cases that had abuse suspicion reflected in ED discharge ICD codes. RESULTS: Of the 216 eligible patients, only 23 (11.5%) patients had ED ICD codes that included the possibility of abuse. Forty-nine (22.7%) had the possibility for abuse documented by physicians as an ED discharge diagnosis. In addition, 53/149 (35.6%) of all admitted patients and 34/55 (61.8%) of confirmed abuse cases included abuse-related admission ICD coding. Female gender was found to be a factor associated with ED ICD abuse codes. CONCLUSION: Current standards of ICD coding result in a significant underestimate of the prevalence of children assessed in the ED and hospital wards for possible and confirmed abusive fracture(s).

Isolated foveal hypoplasia: report of a new case and detailed genetic investigation.

To carry out an ophthalmological and detailed genetic investigation on a 7-year-old boy with isolated foveal hypoplasia. A full ophthalmological examination and optical coherence tomography (OCT) was performed. We also performed a full genome screen for chromosomal abnormalities, and searched for mutations in two genes (GPR143 and OCA2) known to be associated with ocular albinism and PAX6 gene known to be associated with aniridia. His eye examination was normal with no iris transillumination. A fundus examination, however, showed classic signs of foveal hypoplasia. A molecular genetic investigation showed no mutation(s) in all genes screened and no chromosomal deletion(s) and/or duplication(s) were detected. We report a case of isolated foveal hypoplasia where the underlying genetic cause could not be established. We could not rule out other genetic or epigenetic factors contributing to the pathogenesis of isolated foveal hypoplasia.

Immediate changes in pupil size following Laser in situ keratomileusis (LASIK): Pupillometry study.

PURPOSE: To investigate the impact of laser in situ keratomileusis (LASIK) on the change in pupil size immediately after the procedure. METHODS: In a prospective study, measurement of pupil size was assessed in 70 eyes of 35 consecutive patients using a hand-held pupillometer before and immediately after LASIK in mesopic condition at the refractive eye center, Riyadh, Saudi Arabia. RESULTS: The pupil showed mild dilation immediate after LASIK. Mean pupil size before LASIK was 4.10 ± 0.74 and immediate after was 4.74 ± 0.82, P value <0.0001. No association was found with age, sex, central corneal thickness or pre-operative refractive measurements (CCT). CONCLUSION: There is a change in pupil size that immerses immediately after LASIK; postulations suggested for pupillary dilation include the effect of suction ring, post-operative steroid eye drops, dark room, pain and anxiety.