Clinical profile of amblyopia in a tertiary care facility without proper vision screening in Saudi Arabia.

PURPOSE: To evaluate the clinical profile of amblyopia among patients referred to a tertiary care facility in Saudi Arabia. METHODS: All patients between 1 and 14 years presenting to the amblyopia clinic from 2016 to 2020 were retrospectively reviewed. Amblyopia was defined as visual acuity <0.2 LogMAR (20/30) in the worse eye or two-line difference between the two eyes. We classified patients into strabismic, refractive, mixed strabismic, and refractive and deprivation amblyopia. We subclassified our cohort according to age (< and ≥5 years). RESULTS: Three hundred and eighty-three patients (199 male 54%) were seen in our clinic. Seventeen patients were excluded because they did not meet our inclusion criteria. The mean age at presentation was 5.05 ± 2.49 years. Strabismic amblyopia was found in 180 (49%), refractive in 101 (27.6%), mixed in 69 (19%), and deprivation in 16 (4.2%). Anisometropia in 85.25% and isometropia in 14.75%. Hyperopic astigmatism was the most common refractive error in 246 (67.2%). Esotropia was the most common deviation (90%). Strabismic amblyopia was significantly higher in the <5 years group (62.4% vs. 36.7%). While refractive amblyopia was significantly higher in ≥5 years group (38.8% vs. 15.7%) (P < 0.001). CONCLUSION: Strabismic amblyopia was the most commonly diagnosed in our cohort, especially among patients <5 years of age. Refractive amblyopia was more common in older patients and may be under-detected due to the lack of proper vision screening. The implementation of proper vision screening should help in early detection and successful treatment at an early age.

Ophthalmology workforce over a decade in the Kingdom of Saudi Arabia: demographics, distribution, and future challenges.

BACKGROUND: The ophthalmology workforce is an integral component of any health care system. However, the demand for eye care has imposed a heavy burden on this system. Hence, this study aimed to estimate the trends, demographic characteristics, distribution, and variation between Saudi and non-Saudi ophthalmologists and the future challenges of the ophthalmology workforce in the Kingdom of Saudi Arabia (KSA). METHODS: This study was conducted in the KSA and included ophthalmologists practicing from 2010 to 2023. From the Saudi Commission for Health Specialties, we obtained the number, gender, nationality, and rank of ophthalmologists. The geographic distribution of ophthalmologists in the KSA was obtained from the Ministry of Health Statistical Yearbook 2021. RESULTS: As of January 2023, the KSA had a total of 2608 registered ophthalmologists, with approximately 81.06 ophthalmologists per 1,000,000 people. Only 38% of all ophthalmologists in the country were Saudis. The percentage of Saudi female graduates increased from 13.3% to 37.2% over 12 years [Sen's estimator of slope for median increase per year = 1.33 (95% CI 1.22-1.57) graduates; trend test P < 0.001). Additionally, we found that the geographic distribution of ophthalmologists varied (test for homogeneity of rates, P < 0.0001), with the larger regions having a higher concentration of ophthalmologists than the smaller regions (75.6 in Riyadh versus 42.8 in Jazan per 1,000,000 people). However, the World Health Organization's target for the ophthalmologist-to-population ratio has been achieved in all 13 health regions of KSA. CONCLUSION: The recommended ophthalmologist-to-population ratio has been achieved in the KSA, and the number of Saudi ophthalmologists has almost doubled over the past 8 years. However, the majority of ophthalmologists are still non-Saudi, as Saudi ophthalmologists constitute approximately one-third of the ophthalmology workforce in the KSA. The geographical distribution of ophthalmologists varies, which might affect access to care in peripheral regions. In response to the growing demand for eye care in the KSA, several more effective measures might need to be considered.

Evaluation of the efficacy of botulinum toxin injection for the treatment of infantile esotropia.

PURPOSE: The purpose of this study was to investigate the outcomes and complications of botulinum toxin injection (BTX) as the primary treatment of infantile esotropia (IET). METHODS: We included patients with IET who underwent BTX from 2015 to 2020. IET was defined as esotropia present before 12 months of age, with no significant refractive error, or limitation of rotations. We defined success as a postoperative angle of 0-10 prism diopters (PD). RESULTS: Sixty-three patients met our inclusion criteria (38 male patients [60.3%]). The mean age was 18 ± 8 months (range: 10-26), onset 6 ± 4 months (range: 2-10), and follow-up of 29 ± 25 months (range: 4-54). Amblyopia was present in 45 patients (71.4%). Number of BTX was, 1 in 42 (66.7%), 2 in 17 (27%), 3 in 4 (4.8%), and 4 in 1 (1.6%). The 1st BTX mean dose was 7 ± 3 international unit (range: 4-10) and a mean duration of 4 ± 1 min (range: 3-5). The mean preoperative angle of deviation was 42.30 ± 13.73 PD. The mean postoperative angle of deviation was 16.07 ± 16.15 PD (P = 0.0001). At the final follow-up, BTX was successful in 32 (51%) (success after 1st BTX 33.3%, 2nd BTX 46.03%, and 3rd BTX 50.79%). Twelve patients (19%) had undergone surgery due to the failure of BTX. Postoperative observations included transient ptosis 29 (49.2%), transient exotropia 36 (57.14%), inferior oblique overaction 13 (20.6%), vertical deviation 8 (12.7%), and persistent ptosis 1 (1.6%). CONCLUSION: The success rate of BTX for IET was 51%. BTX can be offered as an alternative to surgery to those who cannot undergo prolonged anesthesia or where accurate measurements could not be obtained.

Myopia Progression Among School-Aged Children in the COVID-19 Distance-Learning Era.

Objective: To investigate the effect of online learning and other environmental factors on myopia progression during the Coronavirus pandemic (COVID-19). Methods: A retrospective cohort study from 2018 to 2021. Data from children aged 6-14 were gathered during three visits: pre-pandemic, at the beginning, and during the pandemic. Demographics (hours spent on screens for educational, recreational purposes, outdoors, and type of screen), best-corrected distance visual acuity (BCDVA), uncorrected distance visual acuity (UCDVA), and cycloplegic refraction were gathered. Results: Of 150 patients, 70 [47%] were boys. The mean age was 11 (2.4) years. Participants mainly used mobile phones (62%) and had insufficient outdoor play (88%). Of the 300 eyes, 221 (74%) showed myopia progression. A significant difference in spherical equivalent (SE) was found between pre-pandemic and post-pandemic periods (-0.29 (0.23) D vs -0.40 (0.11) D; p =0.023). Additionally, UCDVA showed a difference between the initial and 1st follow-up visits (0.57 (0.37) vs 0.64 (0.36), p =0.001), and the first and 2nd follow-up visits (0.64 (0.36) vs 0.70 (0.36), p =0.001). Significant hazard ratio for change in SE in patients with higher age (>9 years), (HR [95% confidence interval (CI)], 0.71 [0.51-0.84]), greater recreational screen usage (HR [95% CI], 1.26 [1.15-1.66]), and insufficient outdoor time (HR [95% CI], 1.45 [1.35-1.67]). Conclusion: Myopia progression was accelerated during the COVID-19 pandemic. Younger age, prolonged screen use, and insufficient outdoor time contributed to increased myopia progression. However, the type of device used had no significant effect.

Diclofenac Versus Corticosteroids Following Strabismus Surgery: Systematic Review and Meta-analysis.

The purpose of the current study was to compare outcomes of diclofenac versus corticosteroids following strabismus surgery. A systematic review and meta-analysis were performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An electronic search was performed to include comparative studies of diclofenac versus corticosteroids following strabismus surgery. The analysis was based on fixed and random effect models. Primary outcomes included discomfort, chemosis, inflammation, conjunctival gap, intraocular pressure, and conjunctival injection. Secondary outcomes were conjunctival congestion, discharge, and drop intolerance. Eight studies with a sample of 469 eyes were included. At weeks 1 and 4 postoperatively, there were no statistically significant differences between the diclofenac and corticosteroid groups, except for conjunctival injection at week 1 (mean difference [MD] = -0.21, P = .04) favoring diclofenac. Interestingly, all primary outcomes significantly favored diclofenac at week 2: discomfort (MD = -0.34, P = .03), conjunctival chemosis (MD = -0.16, P = .04), conjunctival inflammation (MD = -0.16, P = .02), conjunctival gap (MD = -0.17, P = .002), intraocular pressure (MD = -2.53, P < .00001), and conjunctival injection (MD = -0.30, P = .03). Moreover, conjunctival congestion was significantly improved for dexamethasone, whereas discharge and drop intolerance was not statistically different. Diclofenac is comparable to various corticosteroids when used following strabismus surgery. However, it is important to note that diclofenac yielded significant improvements in discomfort, conjunctival chemosis, inflammation, conjunctival gap, intraocular pressure, and conjunctival injection, mainly at 2 weeks postoperatively. [J Pediatr Ophthalmol Strabismus. 2023;60(5):312-322.].

Conventional surgery versus botulinum toxin injection for the management of esotropia in children with Down syndrome.

PURPOSE: To compare the success rates of strabismus surgery and botulinum toxin injection (BTX) in treating esotropia in patients with Down syndrome (DS). METHODS: This multicenter retrospective cohort study included all consecutive patients having DS with esotropia between 2014 and 2021 at King Abdullah Specialist Children Hospital, King Abdullah International Medical Research Center, and King Khaled Eye Specialist Hospital, Saudi Arabia. We divided the patients into two groups according to interventions. Success was defined as angle of deviation of <10Δ at final visit. RESULTS: A total of 53 patients were included: 23 in the surgery group and 30 in the BTX group. There were no significant differences between groups with regard to age, sex, diagnosis, spherical equivalent, and preoperative deviation angle. Before the intervention, the median angle of deviation was 30.0Δ (IQR, 30Δ-45Δ) in the surgery group and 37.5Δ (IQR, 28.8Δ-50.0Δ) in the BTX group (P = 0.802). Postoperatively, the median (IQR) deviation angle was 0.0Δ (0.0Δ-16.0Δ) in the surgery group and 22.5Δ (6.75Δ-30.0Δ) in the BTX group (P = 0.006). The success rate in the surgery and BTX groups was 65% and 30%, respectively (P = 0.011). Two patients developed dissociated vertical deviation in the surgery group. One patient presented consecutive exotropia and one inferior oblique overaction in the BTX group. CONCLUSIONS: In this study, conventional surgery showed a higher success rate than BTX in the management of esotropia.

Conventional surgery versus botulinum toxin injections for partially accommodative esotropia.

PURPOSE: To compare the effect of botulinum toxin injection (BTX) to bilateral medial rectus recession (BMR) in partially accommodative esotropia (PAET). METHODS: The medical records of children 1-14 years of age treated for PAET with BMR or BTX between 2010 and 2020 at a single institution were reviewed retrospectively. PAET was defined as residual esotropia of at least 14Δ after 6 weeks of continuous wear of full cycloplegic refraction (> +2.5 D). Success was defined as esotropia of 0Δ-10Δ after a single surgery or ≥1 BTX injections. RESULTS: Of 224 patients, 121 received BTX and 103 underwent BMR. BMR showed a higher success rate than BTX (70.9% vs 53.7% [P = 0.006]). BMR was more successful in males, in patients >5 years of age, and when spherical equivalent was ≤ +5.00 D (79.2%, 74.3%, and 67.5%, resp. [P < 0.05]). Mean follow-up was shorter in the BMR group than in the BTX group (16.7 ± 14.7 vs 31.4 ± 29.5 months [P = 0.0001]). Mean duration of surgery was significantly shorter in the BTX group (5.2 ± 4.3 vs 70.5 ± 31.4 min [P = 0.0001]). Postoperative inferior oblique overaction was more common in the BTX group (7.4%; P = 0.02 [Fisher exact test]), and persistent ptosis was only seen in the BTX group (0.8%); consecutive exotropia was only seen in the BMR group (2%). CONCLUSIONS: In our study cohort, BMR had a higher success rate than BTX. Conventional surgery allowed for shorter follow-up and fewer complications than BTX in the treatment of PAET.

Superior oblique split lengthening procedure for brown syndrome, outcomes and complications.

INTRODUCTION: To evaluate the outcomes of the superior oblique split tendon lengthening (SOSL) procedure for Brown syndrome (BS). METHODS: At a single institution, all patients who underwent SOSL surgery for BS from 2013 to 2019 were reviewed retrospectively. We looked at the surgical outcomes and complications in a total of 20 eyes of 18 patients. The superior oblique (SO) muscle was isolated and then extended. The tendon was then split centrally into equal halves. Two 6-0 polyglactin sutures were then placed on each end of the split tendon 6-10 mm apart. To complete the Z-cut, the split tendon was cut distal to the preplaced sutures. The sutures were then tied to produce the split Z-tendon lengthening. RESULTS: Eleven (55%) out of 20 eyes were female patients. The mean age was 6.6 years (range 2-17 years). The mean follow-up was 26.8 months (range 5-72 months). The mean degree of preoperative limitation of elevation on adduction was -3.6±0.58 preoperatively and -0.75±1.25 postoperatively (p=0.0001). Preoperatively, the mean degree of vertical deviation at near was 3.5±7.62 and at distance was 3.10±7.84 prism diopters (PD), respectively. Postoperatively, the mean vertical deviation was 2.77±4.75 and 2.10±4.08 PD at near and distance, respectively. Postoperative complications included haematoma in one patient (5%), overcorrection in two patients (10%) and one patient required reoperation (5%). CONCLUSION: SOSL is a safe procedure that surgeons can consider in managing patients with BS.

Limbal Versus Fornix Incision for Strabismus Surgery: Preferences from a Consultant to a Trainee Level in Saudi Arabia.

PURPOSE: This study aims to identify the use of limbal versus fornix incisions among strabismus surgeons in Saudi Arabia and the preferred approach to teaching trainees with the shortest learning curve. METHODS: Two designed questionnaires were sent to local strabismus surgeons and ophthalmology trainees. RESULTS: A total of 127 participants responded to our survey: fifty-nine consultants (53% Saudi nationals and 43% expat ophthalmologists) and 68 trainees. The limbal approach was the preferred approach for all settings, including the primary pediatric procedure (30, 55.9%), pediatric reoperation (40, 64.7%), adult primary procedure (32, 55.9%), and reoperation (40, 70%). The reason was attributed to better exposure. As for fornix incision, the most commonly cited reason was less pain and discomfort. For the adjustable suture technique, 29 (49.2%) did not use adjustable sutures, and 22 (37.3%) prefer the limbal approach. When we compared Saudi versus non-Saudi surgeons, 26 (83.87%) Saudi surgeons were trained to perform the limbal method, whereas 16 (57.14%) non-Saudi surgeons were trained to perform the fornix approach. Of the trainees, 35 (51%) were trained on the limbal approach. When asked about the learning curve for different methods, 41 (60.3%) noted a faster learning curve with the limbal approach. CONCLUSION: Despite the many advantages of the fornix incision, it remains uncommon in our region. Each technique of strabismus surgery has its advantages and disadvantages. Programs should teach all methods to trainees. One should add all styles to his armamentarium and choose the appropriate one for each patient.

Diclofenac Versus Dexamethasone Following Strabismus Surgery: A Systematic Review and Meta-Analysis.

Purpose: To compare outcomes of diclofenac versus dexamethasone in patients after strabismus surgery. Methods: A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted on MEDLINE, EMBASE, EMCARE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL). All randomized controlled trials (RCTs) comparing the outcomes of diclofenac versus dexamethasone poststrabismus surgery were included. An extraction spreadsheet for data collection and Review Manager 5.3 were used for data analysis based on the fixed and random effects models. Discomfort, inflammation, chemosis, conjunctival gap, and intraocular pressure (IOP) were primary outcome measures. Secondary outcomes included conjunctival congestion and injection, discharge, and drop intolerance. Fixed and random effects models were used for the analysis. Results: Five RCTs enrolling 248 subjects were enrolled. At week 2 postoperatively, there was a significant difference favoring diclofenac over dexamethasone in terms of discomfort (mean difference [MD] = -0.37, P = 0.02), conjunctival inflammation (MD = -0.16, P = 0.02), conjunctival chemosis (MD = -0.16, P = 0.04), and postoperative conjunctival gap (MD = -0.17, P = 0.002). In terms of IOP, there were no significant differences. However, no statistically significant differences were noted at weeks 1 and 4 postoperatively. For secondary outcomes, dexamethasone had significantly improved conjunctival congestion; however, diclofenac had significantly less injection at the site of muscle attachments at week 2. No significant difference was noted in terms of discharge and drop intolerance. Conclusion: Diclofenac is comparable to dexamethasone when used following strabismus surgery. However, a significant difference favoring diclofenac in terms of discomfort, inflammation, conjunctival chemosis, and conjunctival gap was only noted at 2 weeks postoperatively. The authors suggest conducting further studies to support the effectiveness of diclofenac as an alternative to corticosteroids following strabismus surgery.

Surgical management of strabismus following choroidal melanoma plaque brachytherapy.

PURPOSE: To characterize intraoperative findings, surgical approach, and postoperative outcomes in patients undergoing strabismus surgery following plaque brachytherapy for ocular melanoma. METHODS: The records of all patients who underwent plaque brachytherapy for choroidal melanoma between May 2007 and June 2016 were reviewed retrospectively to identify those who subsequently required strabismus surgery. RESULTS: Of the 461 patients who underwent plaque brachytherapy during the study period, 13 (2.8%) met inclusion criteria. Visual acuity of the affected eye was 20/40 or better in 9 patients (69%). Preoperative horizontal deviation ranged from 0Δ to 52Δ; vertical deviation, from 2Δ to 25Δ. At final follow-up mean horizontal deviation ranged from 0 to 4Δ; vertical deviation, from 0Δ to 12Δ. Intraoperatively, all muscles directly adjacent to the treated area appeared macroscopically thicker than normal despite being functionally underacting. Magnetic resonance imaging showed enlarged muscles adjacent to the plaque radiotherapy. Microscopic examination of muscles in 2 patients showed reactive enlargement of the muscle fibers, granulation tissue, and inflammation. CONCLUSIONS: Persistent strabismus after plaque brachytherapy is rare. Typical findings include enlarged, underacting rectus muscles adjacent to the area of the plaque, restrictive connective tissue, and incomitant strabismus. Previously disinserted muscles may be found in abnormal locations. In this patient cohort scar tissue removal in conjunction with tightening procedures on the muscle adjacent to the plaque combined with recession of the antagonist muscle frequently resulted in good anatomical outcome.