Pediatric bacterial keratitis: clinical features, causative organisms, and outcome during a 13-year study period.

OBJECTIVE: To review the clinical features, causative organisms, complications, and outcomes of patients with pediatric bacterial keratitis at a tertiary care eye hospital. METHODS: We conducted a retrospective study at a tertiary care eye centre on clinically diagnosed pediatric patients with bacterial keratitis between 2007 and 2019. Poor outcomes were labelled if any of the following were present: final best-corrected visual acuity worse than 20/200, a drop in best-corrected visual acuity by 1 line or more, perforated corneas, endophthalmitis, and graft failure. RESULTS: The study included 43 cases of bacterial keratitis. Female and male patients represented 60.5% and 39.5% of the sample, respectively, with a mean age of 9.3 ± 5.9 years. The rate of culture positivity was 60.5%. The most common causative organisms were coagulase-negative Staphylococcus (23.1%), Pseudomonas (23.1%), and Streptococcus pneumoniae (19.2%). Culture-positive bacterial keratitis was associated with infiltrates ≥2 mm (p = 0.039), as determined by the results of multivariate analysis. Gram-positive and gram-negative bacteria exhibited 100% sensitivity to the tested fluoroquinolones. Complications included visually significant scars (55.8%), cataracts (14.0%), perforations (9.3%), corneal neovascularization (7.0%), nonhealing epithelial defects (7.0%), and endophthalmitis (4.7%). Corneal perforation was associated with the development of endophthalmitis (p < 0.001). On multivariate analysis, the only factor associated with a poor outcome was poor presenting visual acuity (p = 0.020). CONCLUSION: Gram-positive bacteria were the most common cause of pediatric microbial keratitis. Positive cultures were associated with larger infiltrates. The only adverse prognostic factor was poor presenting vision.

Differentiation of acanthamoeba keratitis from other non-acanthamoeba keratitis: Risk factors and clinical features.

INTRODUCTION: Infectious Keratitis is one of the most common ocular emergencies seen by ophthalmologists. Our aim is to identify the risk factors and clinical features of Acanthamoeba Keratitis (AK). METHODS: This retrospective chart review study was conducted at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, and included all the microbial keratitis cases, male and female patients of all ages. The main outcome is the differentiation between various microbial keratitis types. RESULTS: We included 134 consecutive eyes of 126 persons. We had 24 cases of acanthamoeba keratitis, 22 bacterial keratitis, 24 fungal keratitis, 32 herpetic keratitis, and 32 bacterial co-infection. Contact lens wear was found in 33 eyes (24.6%). Among acanthamoeba keratitis patients, 73% were ≤ 39 years of age, and 73% were females (P <0.001). Also, in AK cases, epithelial defect was found in all cases (100%), endothelial plaques were found in 18 eyes (69.2%), 12 cases had radial keratoneuritis (46.2%), and ring infiltrate was found in 53.8% of AK cases. CONCLUSIONS: We determined the factors that increase the risk of acanthamoeba infection and the clinical characteristics that help distinguish it from other types of microbial keratitis. Our findings suggest that younger females and patients who wear contact lenses are more likely to develop acanthamoeba keratitis. The occurrence of epitheliopathy, ring infiltrate, radial keratoneuritis, and endothelial plaques indicate the possibility of acanthamoeba infection. Promoting education on wearing contact lenses is essential to reduce the risk of acanthamoeba infection, as it is the most significant risk factor for this infection.

Therapeutic Targets in the Management of Dry Eye Disease Associated with Sjögren's Syndrome: An Updated Review of Current Insights and Future Perspectives.

Dry eye disease (DED) is a continuing medical challenge, further worsened in the autoimmune inflammatory hyperactivation milieu of Sjögren's syndrome (SS) due to disturbances to innate and adaptive immunity with malfunctioning neuro-endocrine control. However, the pathogenetic mechanisms of SS DED are not fully established. This review summarized the available evidence, from systematic reviews, meta-analyses, and randomized clinical trials, for the efficacy and safety of the available ocular therapeutics for the management of SS DED. Relevant studies were obtained from major databases using appropriate keywords. The available largely empirical symptomatic, supportive, and restorative treatments have significant limitations as they do not alter local and systemic disease progression. Topical therapies have expanded to include biologics, surgical approaches, scleral lens fitting, the management of lid margin disease, systemic treatments, nutritional support, and the transplantation of stem cells. They are not curative, as they cannot permanently restore the ocular surface's homeostasis. These approaches are efficacious in the short term in most studies, with more significant variability in outcome measures among studies in the long term. This review offers an interdisciplinary perspective that enriches our understanding of SS DED. This updated review addresses current knowledge gaps and identifies promising areas for future research to overcome this medical challenge.

Incidence, Pathophysiology, Complications, and Management of Positive Vitreous Pressure During Penetrating Keratoplasty: A Literature Review.

Positive vitreous pressure (PVP) is common during open anterior segment surgery and penetrating keratoplasty (PKP) has a reported incidence rate of 40-50%. Despite adequate perioperative preventive precautions, positive pressure occurs during surgery and optimum management of PVP is required to avoid serious complications. Many pharmacological and mechanical approaches can be employed either preoperatively or intraoperatively to decrease vitreous pressure. Surgical techniques such as graft-over-host technique, the modified graft-over-host technique, techniques employed mattress sutures and needle, or Vitreous aspiration or vitrectomy can be effectively used to manage intraoperative PVP during PPK. This article reviews the incidence, risk factors, prevention, and different approaches to the management of positive vitreous pressure during PKP to analyze the available evidence in order to improve the safety profile of PKP and prevent sight-threatening complications.

Bacterial Keratitis: Clinical Features, Causative Organisms, and Outcome During a 13-year Study Period.

PURPOSE: This study aimed to review clinical features, causative organisms, complications, and outcome of bacterial keratitis cases at a tertiary eye hospital. METHODS: A retrospective study was conducted on clinically diagnosed bacterial keratitis cases from 2007 to 2019. Poor outcome was flagged if any of the following was identified: final visual acuity (VA) worse than 20/200, decrease in VA (1 line or worse compared with presenting VA), corneal perforation, endophthalmitis, failed graft, or cases requiring enucleation or evisceration. RESULTS: The study included 263 cases of bacterial keratitis with 169 cases (64.3%) of culture-positive bacterial keratitis. Gram-positive bacteria were found to be the causative organism in 106 cases (62.8%). The most common types were coagulase-negative staphylococci (23.1%) and Pseudomonas (23.1%). Culture-positive bacterial keratitis was associated with the development of anterior chamber reaction (≥1+) on multivariate analysis [adjusted odds ratio (OR): 3.03, confidence interval (CI): 1.23-7.45, P = 0.016]. The complications that occurred in the current cohort included visually significant scar (64.7%), perforation (10.8%), cataract (8.8%), nonhealing epithelial defects (8.0%), corneal neovascularization (4.9%), endophthalmitis (4.6%), and hypotony (1.5%). On multivariate analysis, diabetes mellitus (adjusted OR: 3.51, CI: 1.59-7.76, P = 0.002), poor presenting best-corrected VA (adjusted OR: 3.95, CI 1.96-7.96, P < 0.001), and positive cultures (adjusted OR: 2.36, CI: 1.11-5.00, P = 0.025) were associated with poor outcome. CONCLUSIONS: Culture-negative keratitis had less severe infection and better outcomes when compared to culture-positive bacterial keratitis. Factors associated with poor outcome included diabetes, poor presenting VA, and positive cultures.

Innovative Reconstructive Management of Foot Macrodactyly in a Pediatric Patient: A Case Report.

Macrodactyly is a rare congenital anomaly characterized by disproportionate hypertrophy of one or more digits or the forefoot, involving some or all tissue types. It is nonhereditary and can present alone or alongside other deformities. Usually, macrodactyly is treated with amputation of the affected toe or finger to reduce the chance of recurrence. In this paper, we present the case of a child with macrodactyly who was treated successfully without amputation and instead with a reconstruction of the toe shape to resemble a near-natural-looking toe with intact functions. The patient was a one-year-old female who presented with macrodactyly of her right great toe, right second toe, and forefoot. She had no history of other congenital deformities or systemic diseases. A reconstruction surgery was performed, which involved debulking the right great toe, right second toe, and forefoot. Also, it included the creation of the first web space and the restoration of the nailbed of the second toe. Postoperative follow-up revealed minimal complications. Thus, a second reconstructive surgery was performed, which included debulking and further reconstruction of the foot to improve the result. Several techniques exist for the reduction of macrodactyly that can achieve optimal results. The choice of technique depends on the specifics of the case and the experience of the surgeon. We therefore hope our technique will be beneficial for the management of future cases of macrodactyly. One year of follow-up after the second operation revealed maintained function and no regrowth recurrence.

Community Knowledge, Attitude, and Practices Related to Strabismus and Strabismus Treatment and Surgery in Al-Jouf Region, Saudi Arabia.

BACKGROUND: Strabismus is the misalignment of the visual axis of both eyes caused by abnormalities in binocular vision or anomalies of neuromuscular control of ocular motility. This study aimed to assess the community knowledge, attitude, and practices related to strabismus and strabismus treatment and surgery in the Al-Jouf region of Saudi Arabia. METHODS: This study utilized a quantitative cross-sectional design. The consented volunteering adult participants were randomly selected through sequential enrollment to the completion of the target sample size from five population groups constituting the Al-Jouf region of Saudi Arabia. The data were collected through an online validated self-administered questionnaire. The collected data were analyzed using descriptive and inferential statistics. RESULTS: The study included 340 participants; 67.6% of them were females and 32.4% were males. Only 66.8% of participants correctly defined strabismus. Symptoms of strabismus were identified as double vision (58.5%), blurred vision (48.2%), headache (31.8%), eye fatigue (41.5%), and difficulty reading (47.1%). Regarding risk factors of strabismus, 48.5% reported family history, 39.4% reported uncorrected refractive errors, and 23.2% reported long screen time. Complications of untreated strabismus were reported as low self-confidence (39.1%), vision loss (27.6%), poor interpersonal relationships (25.9%), amblyopia (42.6%), and cosmetic stigma (14.1%). Only 45.6% of the participants agreed to marry someone with strabismus or allow their relatives to do so. The majority of participants (72.6%) would advise a strabismus patient to visit an ophthalmologist. Despite a higher knowledge regarding strabismus among females, younger agers, higher education, single persons, workers/students, and those inhabiting the capital city of the region, such association did not reach significance. CONCLUSION: The study shows a moderate level of knowledge, attitude, and practices among the general population of Al-Jouf Saudis toward strabismus. There was no significant relationship between knowledge of strabismus and any of the demographic characteristics of the participants. This might prove detrimental to the early detection and treatment of strabismus to prevent its complications and improve its outcomes and the quality of patients' lives. Institution of correlation plans are mandated by the Ministry of Health and interested stakeholders.

Knowledge, Attitudes, and Practices towards Diabetic Retinopathy among Primary Care Physicians of Saudi Arabia: A Multicenter Cross-Sectional Study.

Primary care physicians play a vital role in preventing the progression of diabetic retinopathy (DR) from the initial stages to the late stages. This questionnaire-based analytical cross-sectional study was carried out to assess the knowledge, attitude, practices, and their correlation among 274 randomly selected primary care physicians in Saudi Arabia. Among the studied population, high knowledge, attitudes, and practice scores were observed in 21.5%, 15%, and 29.2% of the physicians, respectively. The mean knowledge score was significantly higher among the age group of less than 30 years (p = 0.031) and the female gender (p = 0.012). The attitude scores were significantly higher among the Saudi physicians (p = 0.027) and those with PHC work experience of less than five years (p < 0.001). Regarding the practices, a significant association was found among the age group of less than 30 years (p = 0.019) and Saudi physicians (p = 0.003). There was a significant positive correlation between knowledge (correlation coefficient (r) = 0.739, p < 0.001) and attitude (r = 0.479, p = 0.007) with the practice scores. It is recommended that targeted continuous medical education, workshops, and seminars are conducted on the prevention and care of DR among primary care physicians. Furthermore, an exploratory multicenter study that involves primary care physicians belonging to all ministries and private sectors is warranted.

Impact of wearing personal protective equipment on the performance and decision making of surgeons during the COVID-19 pandemic: An observational cross-sectional study.

ABSTRACT: During the coronavirus disease 2019 (COVID-19) pandemic, the mandatory use of personal protective equipment (PPE) has resulted in a significant reduction in the infection rate among health care workers (HCWs). However, there are some ongoing concerns about the negative impact of using PPE for prolonged periods.This study examined the impact of wearing PPE on surgeons' performance and decision making during the COVID-19 pandemic.In this cross-sectional study, an anonymous online questionnaire was created and disseminated to surgeons all over the Eastern Province of Saudi Arabia. The questionnaire included the demographic data, the local hospital policies, the non-technical skills (e.g., communication, vision, and comfort) and the technical skills, and the process of decision making.From June 2020 to August 2020, 162 surgeons participated in this questionnaire. Of them, 80.2% were aged from 26 to 45 years, 70.4% have received a special training for PPE, and 59.3% of participants have operated on COVID-19 confirmed cases. A negative impact of wearing PPE was reported on their overall comfort, vision, and communication skills (92.6%, 95.1%, and 82.8%, respectively). The technical skills and decision making were not significantly affected (60.5% and 72.8%, respectively). More preference for conservative approach, damage control procedures, and/or open approach was reported.Despite its benefits, PPE is associated with a significant negative impact on the non-technical skills (including vision, communication, and comfort) as well as a non-significant negative impact on technical skills and decision making of surgeons. Extra efforts should be directed to improve PPE, especially during lengthy pandemics.

An endothelial rejection line following Descemet stripping automated endothelial keratoplasty.

BACKGROUND: The endothelial rejection line is rarely seen after Descemet stripping automated endothelial keratoplasties (DSAEKs). Here, we present a case of endothelial graft rejection with an endothelial rejection line occurring 1 year after the procedure. CASE PRESENTATION: A 58-year-old female presented with graft rejection 1 year following a DSAEK procedure. The episode started when she tapered down her loteprednol to once a day. Slit-lamp examination showed a mildly injected conjunctiva with 1+ corneal oedema. On the posterior surface of the cornea, there was an endothelial rejection line (Khodadoust line) with keratic precipitates and multiple areas of anterior synechia. CONCLUSION: The classic endothelial rejection line should be kept in mind as a rare sign of DSAEK graft rejection.

Successful surgical management of post-penetrating or deep lamellar keratoplasty Acquired Corneal Sub-Epithelial Hypertrophy (ACSH): A case series.

INTRODUCTION: Acquired Corneal Sub-Epithelial Hypertrophy (ACSH) has been described in patients with peripheral superficial corneal opacities following penetrating keratoplasty and might present similar to Salzmann's nodular degeneration (SND) or peripheral hypertrophic sub-epithelial corneal degeneration (PHSCD). We describe the clinical presentation, topographic findings and the surgical outcome of three cases, which fit the appearance and characteristics of ACSH. PRESENTATION OF CASES: Three patients (3 eyes) with paracentral or peripheral corneal opacification were reviewed to describe their clinical examination (SL), morphology of the opacity (depth, diameter and density) and document their topographic changes before and after surgical intervention by peeling of the epithelium with or without superficial keratectomy under the microscope in addition to brief description of their histopathological examination. DISCUSSION: All 3 cases were secondary to corneal procedures [Penetrating keratoplasty (PKP) in 1 for pseudophakic bullous keratopathy and deep anterior lamellar keratoplasty (DLK) in 2 for advanced keratoconus]. All cases presented with reduced vision, astigmatic changes in topography or manifest refraction. The visual acuity, symptoms, and topographical findings all improved after treatment. Histopathologically, all cases fit the newly described entity of ACSH. CONCLUSION: Careful clinical judgement guided by corneal topography are needed for proper the diagnosis of acquired corneal opacification that results in reduction of vision to identify ACSH from other similar conditions (PHSCD and SND). Peeling of the thickened epithelial and sub-epithelial tissue is curative avoiding the need for corneal re-grafting.

Visual outcomes and patient satisfaction after bilateral implantation of a new trifocal diffractive intraocular lens.

PURPOSE: To assess the visual outcomes, patient satisfaction and spectacle independence following implantation of new diffractive trifocal intraocular lenses. SETTING: 2 centers (university-based practice and a private practice set up). PATIENTS AND METHODS: Prospective nonrandomized study in which 74 AT LISA TRI 839MP and 8 AT LISA TORIC TRI 939MP IOLs implanted bilaterally in 41 patients following either cataract extraction or refractive lensectomy, follow-up was done at 1st, 2nd and 3rd months to assess the visual and refractive outcomes. Also, a questionnaire was used to assess patient satisfaction, spectacle independence and photic phenomena after the surgery. RESULTS: Mean uncorrected monocular distance decimal visual acuity (UDVA) was preoperatively 0.35. The averages of uncorrected monocular distance/intermediate/near (UDVA/UIVA/UNVA) postoperatively were 0.90/0.87/0.91 at 3 months. 87.5% patients had SE within ±0.50 by the 3rd month. Nearly all the patients were satisfied with the surgical outcome and the reported photic phenomena by some patients were non-disturbing with noticeable high level of patient's satisfaction by the third month. CONCLUSION: Diffractive trifocal IOLs can provide with satisfactory visual and refractive results along with positive impact on the performance of vision-related daily activities with minimal level of non-disturbing photic phenomena to patients.

Hospital outbreak of Middle East respiratory syndrome coronavirus.

BACKGROUND: In September 2012, the World Health Organization reported the first cases of pneumonia caused by the novel Middle East respiratory syndrome coronavirus (MERS-CoV). We describe a cluster of health care-acquired MERS-CoV infections. METHODS: Medical records were reviewed for clinical and demographic information and determination of potential contacts and exposures. Case patients and contacts were interviewed. The incubation period and serial interval (the time between the successive onset of symptoms in a chain of transmission) were estimated. Viral RNA was sequenced. RESULTS: Between April 1 and May 23, 2013, a total of 23 cases of MERS-CoV infection were reported in the eastern province of Saudi Arabia. Symptoms included fever in 20 patients (87%), cough in 20 (87%), shortness of breath in 11 (48%), and gastrointestinal symptoms in 8 (35%); 20 patients (87%) presented with abnormal chest radiographs. As of June 12, a total of 15 patients (65%) had died, 6 (26%) had recovered, and 2 (9%) remained hospitalized. The median incubation period was 5.2 days (95% confidence interval [CI], 1.9 to 14.7), and the serial interval was 7.6 days (95% CI, 2.5 to 23.1). A total of 21 of the 23 cases were acquired by person-to-person transmission in hemodialysis units, intensive care units, or in-patient units in three different health care facilities. Sequencing data from four isolates revealed a single monophyletic clade. Among 217 household contacts and more than 200 health care worker contacts whom we identified, MERS-CoV infection developed in 5 family members (3 with laboratory-confirmed cases) and in 2 health care workers (both with laboratory-confirmed cases). CONCLUSIONS: Person-to-person transmission of MERS-CoV can occur in health care settings and may be associated with considerable morbidity. Surveillance and infection-control measures are critical to a global public health response.