Keratoconus: imaging modalities and management.

Background: Keratoconus (KCN) is characterized by gradual thinning and steepening of the cornea, which can lead to significant vision problems owing to high astigmatism, corneal scarring, or even corneal perforation. The detection of KCN in its early stages is crucial for effective treatment. In this review, we describe current advances in the diagnosis and treatment of KCN. Methods: This narrative review focuses on recent advancements in the diagnosis and treatment of KCN, especially evolving approaches and strategies. To ensure the inclusion of the most recent literature, relevant publications discussing advanced imaging techniques and treatment options for KCN were extensively gathered from the PubMed/MEDLINE and Google Scholar databases. The following index terms and keywords were used for the online search: keratoconus, diagnosis of keratoconus, advances in the diagnosis of keratoconus, topography or tomography, anterior segment optical coherence tomography, treatment of keratoconus, advances in the treatment of keratoconus, collagen crosslinking, intrastromal ring, keratoplasty, and new techniques in keratoconus. Results: Various screening methods such as corneal topography, tomography, anterior segment optical coherence tomography, and assessment of corneal biomechanics have been developed to identify KCN in its early stages. After diagnosis, KCN management focuses on preventing disease progression. Corneal collagen crosslinking is a minimally invasive treatment that can slow or stop the progression of the condition. Recent research has also explored the use of copper sulfate eye drops (IVMED-80) as a noninvasive treatment to prevent the progression of KCN. Current treatment options for visual improvement include scleral lenses, intracorneal ring segments, corneal allogeneic intrastromal ring segments, and deep anterior lamellar keratoplasty. Recently, novel alternative procedures, such as isolated Bowman layer transplantation, either as a corneal stromal inlay or onlay, have demonstrated encouraging outcomes. Artificial intelligence has gained acceptance for providing best practices for the diagnosis and management of KCN, and the science of its application is contentiously debated; however, it may not have been sufficiently developed. Conclusions: Early detection and advancements in screening methods using current imaging modalities have improved diagnosis of KCN. Improvement in the accuracy of current screening or diagnostic tests and comparison of their validities are achievable by well-designed, large-scale, prospective studies. The safety and effectiveness of emerging treatments for KCN are currently being investigated. There is an ongoing need for studies to track progress and evaluate clinicians' knowledge and practices in treating patients with KCN. Artificial intelligence capabilities in management approach considering the currently available imaging modalities and treatment options would best benefit the patient.

The Effect of Visual Impairment and Its Severity on Vision-Related and Health-Related Quality of Life in Jordan: A Comparative Cross-Sectional Study.

Purpose: To assess the effect of visual impairment (VI), its severity, and ocular diseases on vision-related and health-related quality of life (QoL) in Jordan. Patients and Methods: A comparative, cross-sectional, hospital-based study was conducted among a group of 278 patients with VI aged ≥ 18 years, and age and sex-matched control group of 278 individuals with no VI. An interviewer administered the National Eye Institute Visual Function Questionnaire (NEI VFQ-25) and the Medical Outcomes Study 12-Item Short Form Health Survey (SF-12) to all participants. Results: All the mean VFQ-25 subscales scores, physical component scale (PCS) and the mental component scale (MCS) of the SF-12 were significantly lower in patients with VI compared to controls with no VI. The VFQ-25 subscales (except general health and ocular pain), PCS, and MCS scores significantly decreased with more severity of VI. In the adjusted multivariate analysis, lower level of education (p=0.013), male sex (p=0.016), and the presence of cerebrovascular disease (p=0.019) were significantly associated with lower VFQ-25 composite scores in visually impaired patients compared to controls. Ocular disease duration of >5 years and progressive VI were significantly associated with lower VFQ-25 composite scores (p= 0.026 and p<0.001) respectively, in patients with VI. Glaucoma had a significantly larger reduction in mean scores of all the VFQ-25 subscales, and the PCS of the SF-12 compared to all other ocular diseases. Conclusion: Both VI and increasing severity of impairment were associated with reduced vision-related and health-related quality of life in adult Jordanians. Glaucoma patients and less educated people were particularly affected. Routine assessment of QoL in visually impaired patients and improving referral protocols to vision rehabilitation services is recommended to improve the QoL in those patients.

Outcomes of Iris-Claw IOL Implantation in Patients with Marfan's Syndrome in Jordan.

Objective: The management of ocular complications of Marfan's syndrome, especially ectopia lentis, is challenging. In this study, we present the effectiveness and the safety of iris-claw intraocular lens (IOL) implantation along with lensectomy for those patients. Also, we compare the practice of implanting these IOLs either in the anterior chamber of retropupillary. Methods: Retrospectively, we included all patients with Marfan's syndrome who underwent lensectomy with iris-claw IOL implantation as a result of ectopia lentis. The patients were categorized into two groups: anterior chamber iris claw IOL and retropupillary iris-claw IOL. The clinical and demographic data, the visual outcome and postoperative complications were compared. Results: Eighteen eyes of 10 patients were included in the study. The mean age of the patients was 19.1 years. Six patients were males. The iris-claw IOL was implanted anteriorly in 13 eyes. The visual outcome was comparable between both groups and most patients achieved improvement in the visual acuity. In addition, the postoperative complications developed similarly in both groups. However, all cases of IOL disenclavation (6 cases) developed in the anterior group. It is revealed that the age of the patient was the most significant factor affecting the occurrence of IOL disenclavation. Conclusion: Iris-claw IOL (either anteriorly or retropupillary) is an effective and relatively safe method in treating ectopia lentis in patients with Marfan's syndrome. In younger patients, anterior iris-claw IOL is safer than retropupillary iris-claw IOL as the risk of disenclavation is higher in younger patients.

Is wearing a face mask associated with symptomatic dry eye disease among medical students during the COVID-19 era? An online survey.

BACKGROUND: Coronavirus disease 2019 has necessitate the routine use of masks worldwide. This study assessed the relationship between wearing a facemask and dry eye disease (DED) among a sample of medical students in Jordan. METHODS: This cross-sectional online survey enrolled medical students from all medical schools in Jordan. The questionnaire, which was shared via social media platforms, assessed sociodemographic information, ocular and medical history, facemask-wearing habits, the use of ocular devices, and the relationship with ocular discomfort. The ocular surface disease index (OSDI) questionnaire was also administered to quantify DED symptoms. RESULTS: A total of 1,219 students participated in this study. In total, 58.3% participants were females, and 52% were in the clinical science years. Symptomatic DED was found in 71.7% of participants. Female sex, basic science years, allergy reporting, and spending more than 6 h looking at screens were significantly associated with symptomatic DED. CONCLUSION: Wearing a facemask was not significantly associated with symptomatic DED. Further studies are needed to investigate the effect of wearing a facemask on the ocular surface.

Preferred Surgical and Anesthesia Techniques for Cataract Surgery in Jordan.

PURPOSE: To study the current practices in Jordan regarding cataract surgical procedures and anesthesia trends for cataract surgery. METHODS: A cross-sectional survey of members of the Jordanian Ophthalmology Society was conducted in October 2020. The questionnaire included questions about participants' demographics, the preferred surgical techniques for cataracts, the preferred anesthesia technique for cataract surgery, the factors which affect the choice of anesthesia technique, the use of sedation, who gives the anesthesia, if there is an anesthesia-trained person who observes the patient during cataract surgery, and the changing trends towards anesthesia between the surgeons. RESULTS: More than half of the respondents (59.1%) had been in practice for more than 5 years. The preferred method for routine cataract was phacoemulsification for most participants (98.4%). For mature cataract, phacoemulsification was the preferred method for 61.4% of participants. More than half (55.1%) used topical with intracameral anesthesia for phacoemulsification. Two thirds of the participants (66.3%) performed retrobulbar anesthesia for extracapsular cataract surgery. In the majority of cases (86.6%), the respondent themself is the one who administers the anesthesia. No sedation was used before surgery in 62.6% of cases. Two thirds of the respondents (70.1%) reported that they had an anesthesia-trained person monitoring the patient during surgery. Patient cooperation was the most important factor (70.9%) affecting the surgeon's choice of anesthesia technique followed by surgeon skill and experience (57.5%). CONCLUSION: Presently, phacoemulsification is the preferred surgical technique for cataract in Jordan. Topical with intracameral anesthesia is the most common anesthesia for phacoemulsification while retrobulbar anesthesia is the most common for extracapsular cataract extraction.

Characteristics of Keratoconus Patients in Jordan: Hospital-Based Population.

PURPOSE: To study the demographic, clinical and topographic characteristics of keratoconus patients in Jordan. METHODS: A retrospective study which was conducted at King Abdullah University Hospital, Northern Jordan. The patients who visited our outpatient clinic from March 2015 to September 2020 and had a definite diagnosis of keratoconus were included in this study. Demographic and clinical data, including age, gender, family history, past ocular history, ophthalmic examination, and topographic parameters, were collected and analysed. Keratoconus severity was classified according to K mean readings. RESULTS: A total of 234 patients with keratoconus were evaluated in this study. The majority of patients (73, 31.2%) were between the ages of 20 and 24. Allergic conjunctivitis was the most frequent past ocular history. Fifty-five patients (23.5%) had a family history of keratoconus. Regarding severity, most of the eyes were mild (63.3%), followed by moderate (24.7%), and then severe (11.9%). The severity of keratoconus was significantly associated with gender (p<0.001). No correlation was found between family history and severity. CONCLUSION: Most of the Keratoconus patients were young, with a mean age of 25.9 years. The majority were mild in severity, with more females presented in the severe stage. The study reported high rate of family history (23.5%) in comparison to similar studies. Therefore, screening of family members of Keratoconus patients is advisable.

COVID-19 Lockdown and Eye Injury: A Case Series from Jordan.

Novel coronavirus or COVID-19 is a viral illness that can cause severe respiratory symptoms. It spreads between people through direct, indirect (through contaminated objects or surfaces), or close contact with infected people via mouth and nose secretions. COVID-19 has caused a worldwide pandemic that necessitated many countries to perform a national lockdown. In Jordan, a complete lockdown was imposed by the government on March 17th, 2020 and continued for more than two months. The lockdown included every single sector in the country. Hospitals were only dealing with outpatient emergency cases, urgent referrals from primary or secondary health institutions and with inpatients whose medical conditions required keeping them admitted. Elective clinics and surgeries were canceled. At the King Abdullah University Hospital (KAUH), which is the only tertiary center in northern Jordan, we dealt with four cases of traumatic eye injury that resulted in a ruptured globe. The four cases were for eyes that had a history of penetrating keratoplasty (PK) and were visually compromised in the involved eye compared to the other eye. The percentage of open globe injuries to the total number of emergency cases presented during the lockdown was significantly higher than the percentage of open globe injuries to the total number of emergency cases presented during the corresponding period in the previous year (p=0.0005). We believe the lockdown inside homes has resulted in higher risk of trauma and rupture globe in this group of patients.

Perception and experience of academic Jordanian ophthalmologists with E-Learning for undergraduate course during the COVID-19 pandemic.

BACKGROUND: Electronic-learning (e-Learning) is a form of education that utilizes information and communications technology to access online teaching and learning. This study aims to evaluate the e-Learning experience among Jordanian academic ophthalmologists during the coronavirus disease 2019 (COVID-19) pandemic. MATERIAL AND METHODS: A cross-sectional survey was applied by using a questionnaire that was distributed among 23 academic ophthalmologists working at 6 medical schools in Jordan during the lockdown. The questionnaire included questions about the ophthalmologists' experience with e-Learning, advantages and disadvantages of e-Learning, interactions of medical students for the e-Learning and the expectations of e-Learning for the future. RESULTS: A total of 22 out of 23 academic ophthalmologists responded. Flexibility of e-Learning to time and place was a major advantage (95.5%), whereas lack of skills was the main obstacle for e-Learning (77.3%). Nineteen participants (86.4%) were not satisfied with e-Learning as the sole method for undergraduate teaching. To improve the original on-campus two-week ophthalmology course, 12 (54.5%) suggested integrating e-Learning into the curriculum, 3 (13.6%) preferred extending the period of training, and 7 (31.8%) reported that their tight schedule does not allow for more tasks. CONCLUSION: The experience of e-Learning was positive. Most believed that e-Learning would have a prominent role in the future of medical education and proposed blended learning programs.

Clinical Experience in the Administration of Intravitreal Injection Therapy at a Tertiary University Hospital in Jordan During the COVID-19 Lockdown.

PURPOSE: To describe the clinical experience with the delivery of intravitreal injection therapy to patients with various indications at a tertiary university hospital during the COVID-19 lockdown in Jordan. METHODS: This is a retrospective observational study of patients who received intravitreal injections between April 12th and May 9th, 2020, a period during the national COVID-19 lockdown (March 16th to June 6th, 2020). Special medical and logistic arrangements, priority and visual risk assessment and strict infection control precautions were implemented. Demographics, diagnosis, intravitreal injection history, medical history, ophthalmic examinations and optical coherence tomography data were collected and analyzed. RESULTS: Intravitreal injections were successfully administered to 132 patients with diabetic retinopathy, age-related macular degeneration and retinal vein occlusion. All logistic and transmission control measures were followed by the medical staff and patients with no incidents. No new exposures or COVID-19 positive cases were traced to our location or time of therapy. No complications related to the injections were recorded. The mean period of delay due to the lockdown from the original scheduled appointment was six weeks. Mean visual acuity significantly decreased from 20/55 before the lockdown to 20/70 after the lockdown, and mean central macular thickness significantly increased from 329 to 370 µ. CONCLUSION: The administration of intravitreal injection therapy during the COVID-19 lockdown under special safety precautions was feasible and successful. Resumption of the essential therapies and medical services during periods of pandemic restrictions while adhering to strict transmission control measures is encouraged.

Awareness, Perceptions, and Attitude Regarding Coronavirus Disease 2019 (COVID-19) Among Ophthalmologists in Jordan: Cross-Sectional Online Survey.

PURPOSE: COVID-19 pandemic is a serious public health concern, and the role of health care workers is essential in preventing spread. The study objective is to investigate awareness, perception, and attitude towards COVID-19 and infection control measures among ophthalmologists in Jordan. METHODS: The design of the study was a cross-sectional survey among Jordanian ophthalmologists. An online survey was sent to 197 ophthalmologists on March 23, 2020. Information on participants' socio-demographic characteristics, knowledge of clinical features of COVID-19, risk assessment and infection control measures for preventing disease transmission, and attitude towards treating patients with COVID-19 were collected. RESULTS: A total of 132 ophthalmologists (mean age 40.5 years) responded, 23 (17.6%) had received training on infection control in ophthalmology. Most ophthalmologists were aware of COVID-19 symptoms and ways to identify patients at risk of having the disease, correctly reported modes of transmission and were aware of measures for preventing COVID-19 transmission in the ophthalmic setup. Social media was the commonest source of information on COVID-19 (75%), and 38.2% were not provided with instructions on infection control plan to reduce transmission of COVID-19. Most ophthalmologists (79.5%) thought that the virus could be detected in tears, and 72.2% thought that red eye as a symptom of COVID-19. CONCLUSION: Ophthalmologists in Jordan were aware of the epidemiology of COVID-19 and related infection preventive measures. Knowledge was lacking regarding ocular aspects of the disease. Training on infection prevention needs to be improved. Access to guidelines from international ophthalmological organizations should be promoted and seeking updated literature from peer-reviewed journals needs to be encouraged.