Eradicating primary congenital glaucoma from Saudi Arabia: The case for a national screening program.

The prevalence of primary congenital glaucoma (PCG) in Saudi Arabia is high and the condition is a cause of childhood blindness in the country. Children often present with severe disease, requiring multiple procedures and a lifetime of medical care. The social and economic burden of the condition is substantial. Presently, the mainstay of management is early diagnosis and treatment of PCG. Premarital screening, especially in recessive diseases, such as PCG can be immensely useful by detecting the presence of a defect in the causative gene, followed by genetic counseling to potential couples that will lead to eradication of the disease in future generations. The introduction of a national screening program similar to the one already functioning for thalassemia, could potentially eliminate childhood blindness from PCG in Saudi Arabia and is likely to prove cost-effective.

Subconjunctival injectable dendrimer-dexamethasone gel for the treatment of corneal inflammation.

Corneal inflammation is often encountered as a key pathological event in many corneal diseases. Current treatments involve topical corticosteroids which require frequent instillations due to rapid tear turnover, causing side-effects such as corneal toxicity and elevated intraocular pressure (IOP). Hence, new interventions that can reduce side effects, dosing frequency, and increase patient compliance can be highly beneficial. In this study, we explore a subconjunctival injectable gel based on G4-PAMAM dendrimer and hyaluronic acid, cross-linked using thiol-ene click chemistry, incorporated with dendrimer dexamethasone (D-Dex) conjugates as a potential strategy for sustained delivery and enhanced bioavailability of corticosteroids. The efficacy of the injectable gel formulation was evaluated in a rat mild alkali burn model. Fluorescently-labelled dendrimers (D-Cy5) incorporated in the gel release D-Cy5 in vivo. The released D-Cy5 selectively targets and localizes within corneal macrophages in inflamed rat cornea but not in healthy controls. This pathology dependent biodistribution was exploited for drug delivery, by incorporating D-Dex in the injectable gel. The attenuation of corneal inflammation by D-Dex gels was assessed using various clinical and biochemical parameters over a 2-week period. Subconjunctival D-Dex gel treatment resulted in favorable clinically-relevant outcomes with reduced central corneal thickness and improved corneal clarity compared to free-Dex and placebo gel controls. The extent of corneal neovascularization was significantly reduced in the D-Dex group. These findings suggest that D-Dex attenuates corneal inflammation more effectively than free-Dex by attenuating macrophage infiltration and pro-inflammatory cytokines expression. A significant elevation in IOP was not observed in the D-Dex group but was observed in the free-Dex group. This novel injectable D-Dex gel may be a potential drug delivery platform for the treatment of many inflammatory ocular surface disorders such as dry eye, auto-immune keratitis and post-surgical complications where frequent steroid administration is required.

Determinants of Visual Outcomes in Femtosecond Laser Assisted Cataract Surgery and Phacoemulsification: A Nested Case Control Study.

PURPOSE: We present the visual outcomes 6 weeks following Femtosecond laser assisted cataract surgery (FLACS) and conventional phacoemulsification cataract extraction (CE) cataract surgeries in 2013. MATERIALS AND METHODS: This was a review of health record type of study. Eyes operated by FLACS and an equal number of conventional phacoemulsification (CE) on the same day by same surgeon were included in the study. Demographics, preoperative status, operative details and the best-corrected visual acuity (BCVA) at 6-8 weeks following surgery were noted. BCVA of >20/60 was considered as excellent. The rate and determinants of excellent vision were calculated. RESULT: Study population comprised of 154 eyes. Both FLACS and CL groups had 77 eyes. Visual acuity at 6-8 weeks was excellent in 44 (60%) eyes of FLACS group and 36 (40%) eyes of CE. Visual outcome following FLACS and conventional surgery was not different (Odd's ratio [OR] 1.5 [95% confidence intervals [CI]: 0.8-2.9]). Operating surgeon did not significantly influence the visual outcomes following FLACS (OR = 1.6) and CE (OR = 0.4). Association of the grade of lens opacities to the visual outcome was not affected by type of surgery (χ(2) = 0.5, P = 0.2). The duration of surgery in CE and FLACS groups was not significantly different (-3.2 min [95% CI: -13; 6.6]). CONCLUSION: Visual outcomes at 6-8 weeks following CE were not different from FLACS. Visual outcomes following FLACS and CE were not influenced by the operating surgeon or severity of the cataract. The time required for FLACS was greater than that required for CE.

Long-term follow-up and visual outcome after excision of a traumatic iris cyst by viscoelastic dissection.

To report the long-term follow-up and visual outcome after excision of a traumatic iris cyst. A 4-year-old female presented with an iris cyst in her left eye 2 years after corneal laceration repair. An 8 × 7 mm cyst was located between 1 and 6 O'clock on the iris, extending into the anterior chamber. The cyst was surgically removed by dissection from the endothelium and angle by viscoelastic and was submitted for histopathological examination. Postoperative outcomes including visual acuity (VA) and complications over 8 years are reported. Histopathological examination demonstrated fragments of iris tissue extensively covered by a layer of epithelial cells which were present on both the anterior and posterior surfaces of portions of the iris stroma. 8 years post-excision, the patient's VA improved from 20/80 to 20/30 with no evidence of recurrence and no adverse sequelae. Traumatic iris cyst is a diagnostic and therapeutic challenge for ophthalmic surgeons with an overall poor visual prognosis if it is not excised properly. Improved wound management techniques during the repair of a traumatic wound are highly recommended. Careful viscoelastic dissection of the iris cyst from the endothelium and angle provided acceptable long-term outcome and prevented recurrence.

Outcome of primary adult optical penetrating keratoplasty with imported donor corneas.

PURPOSE: To evaluate the outcome of primary adult optical penetrating keratoplasty (PKP) performed with internationally acquired donor tissue. PATIENTS AND METHODS: A retrospective review was performed of the medical records of every patient 12 years of age or older who underwent PKP for keratoconus, corneal edema, stromal scarring, or stromal dystrophy at King Khaled Eye Specialist Hospital in the Kingdom of Saudi Arabia between January 1, 1997 and December 31, 2001, and for whom a minimum of 3 months' follow-up was available. RESULTS: Of 885 eyes that met the inclusion criteria, there were 453 eyes with keratoconus, 180 eyes with corneal edema, 171 eyes with stromal scarring, and 81 eyes with stromal dystrophy. For the entire group, the probability of graft survival was 96.9% at 1 year, 86.0% at 3 years, and 80.3% at 5 years. The 5-year probability of graft survival was 96.2% for keratoconus, 39.4% for corneal edema, 71.1% for stromal scarring, and 85.2% for stromal dystrophy. Increasing donor age was significantly associated with an increased risk of graft failure on multivariate Cox proportional hazard regression analysis (P = 0.005). Endothelial cell density, death-to-preservation time, and preservation-to-surgery time were not significantly associated with an increased risk of graft failure. CONCLUSIONS: In our patient population, excellent graft survival was achieved utilizing internationally acquired donor tissue for eyes with keratoconus, stromal dystrophy, and stromal scarring, but not for those with corneal edema.

Outcome of primary adult penetrating keratoplasty in a Saudi Arabian population.

PURPOSE: To evaluate the outcome of primary adult optical penetrating keratoplasty (PKP) in a Saudi Arabian population. PATIENTS AND METHODS: A retrospective review was performed of the medical records of every Saudi Arabian patient 12 years of age or older who underwent PKP for keratoconus, corneal edema, stromal scarring, or stromal dystrophy at King Khaled Eye Specialist Hospital between January 1, 1997, and December 31, 2001, and for whom a minimum of 3 months of follow-up was available. RESULTS: Of 910 eyes that met the inclusion criteria, there were 464 eyes with keratoconus, 188 eyes with corneal edema, 175 eyes with stromal scarring, and 83 eyes with stromal dystrophy. The 5-year survival probability was 96.1% for keratoconus, 71.1% for stromal scarring, 85.9% for stromal dystrophy, and 40.3% for corneal edema. The most significant risk factor affecting graft survival was surgical indication (P < 0.001). Among eyes with corneal edema, increasing donor age (P = 0.004) and the occurrence of one or more complications (P < 0.001) were significantly associated with an increased risk of graft failure. Overall, improvement in vision occurred in 750 (82.4%) eyes, remained the same in 97 (10.7%) eyes, and worsened in 63 (6.9%) eyes. CONCLUSION: In the Saudi Arabian population, the prognosis for graft survival and improved visual acuity is excellent for eyes with keratoconus and stromal dystrophy, good for stromal scarring, and poor for eyes with corneal edema.

Traumatic epithelial inclusion cyst of the anterior corneal stroma.

PURPOSE: To report a case of posttraumatic epithelial inclusion cyst of the anterior corneal stroma. METHODS: Case report. RESULTS: A 17-year-old girl presented with a large painless mass of the right cornea. After simple surgical excision, histopathologic examination confirmed the diagnosis. There was no recurrence during a 2-year period of follow-up. CONCLUSIONS: Traumatic epithelial inclusion cysts can be easily managed with simple surgical excision.

Fixed dilated pupil after penetrating keratoplasty for macular corneal dystrophy and keratoconus.

PURPOSE: To identify predisposed eyes, risk factors, and protective measures and to evaluate methods of treatment for fixed dilated pupil after penetrating keratoplasty (PKP) for macular corneal dystrophy (MCD) and keratoconus. DESIGN: Retrospective observational case series. METHODS: A retrospective review was conducted of the charts of 195 patients who had PKP for MCD and of 1800 patients who had PKP for keratoconus at the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia. The review included an evaluation of the preoperative and intraoperative data and the postoperative course. In addition, clinical examinations at the last visit and photographs of the cornea, pupil, iris, and lens were analyzed. RESULTS: Twenty-one eyes of 18 patients had fixed dilated pupil after PKP; 15 eyes of 12 patients had MCD, and six eyes of six patients had keratoconus. A rise in intraocular pressure (IOP) during the procedure was seen in five patients (23.8%). Fixed dilated pupil was documented on the first and second postoperative days and the second postoperative week in 17 (80.9%), one (4.8%), and three (14.3%) eyes, respectively. Six eyes (28.6%) of six patients had severe eye inflammation. Only one eye (4.8%) regained partial reactivity of the pupil on follow-up visits. Seven eyes (33.3%) experienced lens changes; nine eyes (42.8%) had elevated IOP on the first postoperative day, and none of the eyes had chronic glaucoma. CONCLUSION: Inflammatory and multifactorial pathologic condition can cause fixed pupil after PKP. Atropine use, keratoconus, and high IOP are not constant findings in this syndrome. Awareness of the risk factors of fixed dilated pupil will help prevent against its occurrence.

Microbial keratitis after amniotic membrane transplantation.

PURPOSE: To determine the incidence of early-onset (<30 days) and late-onset (>30 days) microbial keratitis after treatment of persistent corneal epithelial defects with amniotic membrane transplantation (AMT) utilizing tissue acquired from a commercial laboratory or prepared by the institutional eye bank. METHODS: A retrospective, non-randomized, sequential, comparative study was performed for every patient with a persistent corneal epithelial defect who underwent primary AMT at KKESH between January 1, 2003 and June 30, 2004. RESULTS: A total of 142 AMT procedures were performed for persistent corneal epithelial defects during the study period. There were 72 cases using commercially prepared tissue and 70 cases using locally prepared tissue. The mean patient age was 50.3+/-25.6 years (range, 1-104 years). The mean follow up was 6.3+/-5.0 months (range, 1-21 months). There were no cases of early-onset microbial keratitis in cases in which either commercially acquired tissue or locally prepared tissue was used. CONCLUSION: Amniotic tissue prepared in a commercial laboratory or by properly qualified eye bank personnel may be used for AMT in eyes with persistent corneal epithelial defects with minimal risk of microbial keratitis in the first postoperative month.

Changing indications for corneal transplantation at the King Khaled Eye Specialist Hospital (1983-2002).

PURPOSE: To identify changing indications for keratoplasty over the last 20 years at a tertiary care eye hospital in a country with rapidly evolving ophthalmic care services. METHODS: A retrospective review was performed of the eye bank records of every patient who received a lamellar or penetrating keratoplasty at the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia, between January 1, 1983 and December 31, 2002. For each case, the primary surgical indication was identified. RESULTS: A total of 8318 corneal transplants were performed during this 20-year period. In the first 5 years of the study, the leading indications for corneal transplantation were corneal scarring (52.0%), aphakic/pseudophakic bullous keratopathy (13.5%), corneal degeneration (10.0%), and keratoconus (7.6%). During the last 5 years of the study, the leading indications for corneal transplantation were keratoconus (40.2%), corneal scarring (19.8%), failed corneal transplant (11.3%), and corneal ulceration (10.2%). There was a dramatic increase in the number of transplants performed for keratoconus (441%) and failed corneal transplants (285%) as well as a dramatic decrease in the number of transplants performed for corneal degeneration (-88%) and scarring (-60%) between the first and last 5 years of the study period. CONCLUSIONS: Major changes in the indications for corneal transplantation were related to the introduction and expansion of modern ophthalmic services at a time of rapid socioeconomic development and population growth.

Corneal honeybee sting.

PURPOSE: To report a rare case of corneal honeybee sting. METHODS: The corneal honeybee stinger was removed under slit-lamp guidance using a 27-gauge needle. RESULTS: Corneal edema resolved by 90% the next day after removal of the honeybee stinger without using topical steroids. CONCLUSION: The patient's condition improved significantly after removal of the corneal honeybee stinger, and corneal edema disappeared. The patient was evaluated in 1 week and then 3 months with permanent mild central corneal opacity.