Abdullah M. Alfawaz

Cytomegalovirus-related corneal endotheliitis: A review article

Cytomegalovirus (CMV)-related corneal endotheliitis is an inflammation of the corneal endothelium caused by CMV. It typically presents as coin-shaped keratic precipitates (KPs), with or without corneal edema, in otherwise healthy individuals. It may be associated with anterior uveitis and raised intraocular pressure (IOP). Patients with CMV-related corneal endotheliitis respond to systemic and topical ganciclovir with the use of topical steroid. Making an accurate early diagnosis is crucial in preventing loss of corneal endothelial cells and unnecessary treatment resulting from misdiagnosis in these patients.

Efficacy of punctal occlusion in management of dry eyes after laser in situ keratomileusis for myopia.

Abstract Purpose: To evaluate the effect of punctal plug use in preventing dry eye after laser in situ keratomileusis (LASIK). Materials and Methods: A randomized clinical trial at a tertiary eye care center, Riyadh, Saudi Arabia. Participants underwent LASIK for myopia in both eyes and a lower punctal occlusion in one eye only while the other eye served as control. Both eyes received the same postoperative medications except for lubricant duration (subject eye: four times per day for one week; control eye: four times per day for 6 months). Participants were evaluated at 1 week, 2, and 6 months after surgery for signs and symptoms of dry eye. The main outcome measures were visual acuity; ocular surface parameters; and Ocular Surface Disease Index questionnaire. Results: Seventy-eight eyes of 39 patients were included in this study. The Ocular Surface Disease Index scores of eyes with punctal plugs were better at all follow-up visits, and the differences between both eyes were statistically significant (1 week, p < 0.0001; 2 months, p < 0.0001; 6 months, p = 0.008). At the final follow-up visit, the percentage of normal eyes was higher in eyes with punctal plugs for all ocular surface parameters (Schirmer 1 test, 94.9%; tear breakup time, 77.8%; punctate epithelial keratitis score, 71.8%) compared to eyes without occlusion (Schirmer 1 test, 92.3%; tear breakup time, 58.3%; punctate epithelial keratitis score, 53.8%); however, such differences were not statistically significant. Conclusion: Punctal plug insertion after LASIK surgeries may minimize the need for frequent lubricant application and hence improve patient satisfaction.

Nongranulomatous anterior uveitis in a patient with Usher syndrome

A 34-year-old female with Usher syndrome, but no family history of similar illness, presented with complaints of vision reduction, redness, and photophobia. Biomicroscopic examination showed mildly injected conjunctivae bilateral, small, round keratic precipitates; bilateral +2 cells with no flare reaction in the anterior chamber; and bilateral posterior subcapsular cataracts. No associated posterior synechiae, angle neovascularization, or iris changes were detected; normal intraocular pressures were obtained. Fundus examination demonstrated waxy pallor of both optic nerves, marked vasoconstriction in retinal vessels, and retinal bone spicule pigment formation, with a normal macula. Electroretinography confirmed the diagnosis of retinitis pigmentosa, optical coherent tomography was normal and otolaryngology consultation was conducted. To our knowledge, an association between Usher syndrome and bilateral nongranulomatous anterior uveitis has not been previously reported, and our purpose is to report this association.

Clinical features and visual outcomes of scleritis patients presented to tertiary care eye centers in Saudi Arabia

AIM To describe the clinical features, systemic associations, treatment and visual outcomes in Saudi patients with scleritis. METHODS A retrospective chart review was performed for patients with scleritis presenting to two tertiary care eye hospitals in Riyadh, Saudi Arabia, from 2001 to 2011. Data were collected on the clinical features of scleritis, subtypes of scleritis, associated systemic disease, history of previous ocular surgery and medical therapy, including the use of immunosuppressants. Treatment outcomes were evaluated based on best-corrected visual acuity (BCVA) and response to treatment. RESULTS Of the 52 patients included in the study, non-necrotizing anterior scleritis was the most common type of scleritis in 22 patients (42.3%), followed by posterior scleritis in 14 patients (26.9%). The majority of cases, 31 patients (59.6%), were idiopathic in nature. Systemic associations were present in 12 patients (23.1%). Infectious scleritis was confirmed in 6 patients (11.5%): 3 with bacterial scleritis after pterygium excision, 2 patients with scleritis related to tuberculosis and 1 patient with scleritis resulting from herpes simplex infection. For the various subtypes of scleritis, BCVA values after treatment and time to remission significantly differed (P<0.05, all cases). Systemic immunosuppressive therapies in addition to steroids were administered to 46.2% of all patients. The T-sign was present on B-scan ultrasonography in 9 (64.3%) of the 14 posterior scleritis patients. CONCLUSION Non-necrotizing anterior scleritis was the most common subtype of scleritis. Final visual outcome and time to remission differed among the various scleritis subtypes.

Radial Keratoneuritis as a Presenting Sign in Acanthamoeba Keratitis

The visual outcomes of Acanthamoeba keratitis, a rare cause of corneal infection, can be devastating. This paper reports two contact lens wearers with severe pain and photophobia who presented to the emergency room. Biomicroscopy revealed radial keratoneuritis in both individuals. Tissue culture on a nonnutrient agar plate with Escherichia coli overlay resulted in a heavy growth of Acanthamoeba. The inpatient treatment included 0.02% polyhexamethylene biguanide, chlorhexidine, neomycin/polymyxin B/bacitracin (Neosporin), and oral fluconazole, which successfully controlled the corneal infection and improvement in the best corrected visual acuity in both patients. Infection did not recur during the 12-month follow-up period. Acanthamoeba keratitis can present as radial keratoneuritis, mimicking other common corneal infections resulting in diagnostic and treatment delays. Early diagnosis and prudent treatment of Acanthamoeba keratitis are the keys to restoring vision and avoiding the subsequent need for penetrating keratoplasty.

Incidence, Risk Factors and Surgical Outcomes of Cataract among Patients with Uveitis in a University Referral Hospital in Riyadh, Saudi Arabia

ABSTRACT Purpose: To investigate incidence, risk factors, and surgical outcomes of cataract among uveitis patients. Methods: Retrospective review of 1000 patients (1582 eyes). Results: At initial presentation, cataract was diagnosed in 290 (18.3%) eyes and was most common in eyes with anterior uveitis. Fuchs’ uveitis, herpetic uveitis, and presumed tuberculous uveitis were leading clinical entities associated with cataract at presentation. During follow-up, cataract developed in additional 200 (12.6%) eyes and was most common in eyes with anterior uveitis. Significant risk factors at presentation included age >18 years, female gender, presence of keratic precipitates, hypopyon, and posterior synechiae. Among the 490 eyes with cataract, 204 underwent cataract extraction during follow-up period. Best corrected vision of ≥20/40 was achieved in 122 (60.1%) eyes. Conclusions: Incidence of cataract differed depending on anatomic and etiologic diagnoses of uveitis. There is a significant association between severity of inflammation at presentation and development of cataract.

Management of traumatic corneal abrasion by a sample of practicing ophthalmologists in Saudi Arabia

Purpose Corneal epithelial defect (CED) is a common medical emergency condition involving loss of surface epithelial layer of the cornea. The aim of the study is to explore the practice patterns of ophthalmologists in management of traumatic CED in Saudi Arabia and to assess the variance in clinical practice from the established clinical practice guidelines. Methods A Survey based study at King Abdulaziz University Hospital between March 2015 and January 2016. A survey of 16 relevant closed ended questions was distributed to 300 practicing ophthalmologists including Saudi Ophthalmology Society (SOS) members and non-members. The survey questionnaire focused on the known aspects of traumatic CED management. Results 188 practicing ophthalmologists responded to the distributed questionnaire. That represents a 63% response rate for the present survey study. The age group most commonly affected by traumatic CED is 6–18 years old (61.2%). Fingernail trauma (n = 129, 68.6%) was the major cause of CED reported by respondents. In large CED (>5 mm) most common modality of treatment is pressure patching with topical antibiotics with or without cycloplegics (40.4%) whereas in small CED (<2 mm) topical antibiotics and cycloplegics is the preferred way (40.4%). The most commonly used prophylactic antibiotic was second-generation fluroquinolons (58.5%). Conclusions Present study demonstrates that practicing ophthalmologists are reporting that traumatic CED mostly affects young people and fingernail trauma is the major cause. There is lack of clear institutional guidelines and consensus on the management of traumatic corneal abrasions.

Self-Inflicted Eye Injury

Individuals with a factitious ocular disorder feign or exaggerate having an eye injury or intentionally produce an eye injury so as to assume the role of a sick person. We report two cases of self-inflicted ocular injury using needle-like foreign bodies and razor that represent possible diagnoses of Munchausen syndrome. Both patients presented with different clinical pictures that misguided the clinical diagnosis and delayed proper management. Although self-inflicted ocular injuries are rare, ophthalmologists should be aware of the possibility of their existence, particularly when caring for patients with psychiatric conditions.

Successful cataract surgery in a patient with refractory Wegener’s granulomatosis effectively treated with rituximab: A case report

Wegener’s granulomatosis is a granulomatous disorder associated with systemic necrotizing vasculitis. Eye involvement occurs in approximately 50% of Wegener’s granulomatosis patients and is an important cause of morbidity. Conventional treatment-related morbidity and failure have led to studies of alternative treatment modalities. In this case of a 35-year-old man with severe Wegener’s granulomatosis, conventional therapy failed to induce remission. Despite the standard immunosuppressive therapy, progression of the disease was observed, mainly with ocular manifestations and renal impairment. Rituximab was given intravenously and led to remission of both systemic and ocular manifestations of the disease. After 1 year of disease quiescence, he was admitted one week after his third regularly-scheduled rituximab treatment and was started on intravenous methylprednisolone, 500 mg/day for 3 days, before cataract surgery. Subsequently, the patient underwent phacoemulsification cataract surgery in his left eye. Six months later, in the same manner he underwent uneventful phacoemulsification cataract surgery in the right eye with a favorable outcome in both eyes. Conclusion: In this patient, rituximab was a well-tolerated and effective remission induction agent for severe refractory Wegener’s granulomatosis and led to successful cataract surgery.

Predictors of performance in an ophthalmology residency program

OBJECTIVE To assess the value of current selection criteria and additional factors as predictors of performance in an ophthalmology residency training program. DESIGN A retrospective study. PARTICIPANTS Data were collected from the files of 166 residents who were collectively trained in an ophthalmology residency program from 2000 to 2013. METHODS The programs selection criteria included medical school grade point average (GPA), Saudi licensing examination (SLE) score, multiple-choice question ophthalmology selection (MCQ) examination score, and interview mark. Indicators of performance included average scores in the promotion examination for 4 years of training (average R), King Saud University fellowship examination (KSU) score, and Saudi Board in Ophthalmology examination (SBO) score. An average of KSU and SBO scores was also used as a performance indicator. Times of program completion and average performance score across all years in the residency program were used as second-level indicators of performance. RESULTS There were strong correlations between the MCQ examination score and each training performance indicator (average R, KSU score, SBO score, and average of KSU and SBO scores; p = 0.002, 0.008, 0.05, and 0.002, respectively). The interview mark correlated well with average R (p = 0.001) but not with other indicators. The MCQ examination score and the interview mark were the only predictors of second-level indicators of performance (p = 0.009 and 0.029, respectively). CONCLUSIONS The MCQ examination score and interview mark were the 2 best predictors of performance as an ophthalmology resident. GPA and SLE score were poor predictors of performance.