Elias Chelala

Bilateral macular injury from a green laser pointer

We report the case of a 13-year-old boy who had a bilateral macular injury after playing with a green laser pointer for a duration of 1 minute. Clinical examination revealed a decrease in visual acuity and macular injury in both eyes, and imaging investigations revealed a bilateral macular lesion due to exposure to the laser pointer. At 3 months’ follow up, visual function had improved but remained partially impaired. This case emphasizes the importance of cautious and appropriate use of laser pointer devices because of the potential vision-threatening hazards induced by mishandling of these devices.

Photorefractive keratectomy in patients with mild to moderate stable keratoconus: a five-year prospective follow-up study.

Background The purpose of this study was to evaluate the visual outcome of photorefractive keratectomy (PRK) in patients with mild to moderate stable keratoconus and to assess the risk of progression of the disease after the excimer laser procedure. Methods In this prospective study, carried out at the Clemenceau Medical Center, an affiliate of Johns Hopkins International, in Beirut, Lebanon, 119 eyes from 72 patients with grade 1–2 keratoconus (Amsler–Krumeich classification) underwent PRK. Forty-seven patients had both eyes treated and 25 patients had one eye treated. The procedure was done using the Wavelight Eye Q Excimer laser. Uncorrected and best-corrected visual acuity, corneal topography, and pachymetry were assessed before the procedure and 3, 6, 12, 36, and 60 months after the procedure. Results Mean uncorrected visual acuity showed a statistically significant improvement (P < 0.05) at one, 3, and 5 years follow-up. One hundred and seventeen eyes (98.3%) showed no progression while two eyes (1.7%) showed progression of the disease at 5 years follow-up, as documented by corneal topography and pachymetry. These two eyes were treated with corneal collagen crosslinking. Conclusion PRK in mild to moderate keratoconus is a safe and effective procedure for improving uncorrected vision in patients with mild refractive errors. However, close follow-up of patients is needed to detect any progression of the disease. Longer follow-up is needed to assess the overall effect of this procedure on progression of the disease.

Safety and Visual Outcome of Visian Toric ICL Implantation after Corneal Collagen Cross-Linking in Keratoconus: Up to 2 Years of Follow-Up

Purpose. To evaluate the long-term safety and clinical outcome of phakic Visian toric implantable collamer lens (ICL) insertion after corneal collagen cross-linking (CXL) in progressive keratoconus. Methods. This was a retrospective study of 30 eyes (19 patients), with progressive keratoconus, who underwent sequential CXL followed by Visian toric ICL implantation after 6 months. Results. At baseline, 6 eyes had stage I, 14 eyes stage II, and 10 eyes stage III keratoconus graded by Amsler-Krumeich classification. At 6 months after CXL, only K (steep) and K (max) decreased significantly from baseline, with no change in visual acuity or refraction. Flattening in keratometric readings was stable thereafter. There was significant improvement in mean uncorrected distance visual acuity (1.57 ± 0.56 to 0.17 ± 0.06 logMAR, P < 0.001) and mean corrected distance visual acuity (0.17 ± 0.08 to 0.11 ± 0.05 logMAR, P < 0.001) at 12 months after ICL implantation that was maintained at the 2-year follow-up. Mean cylinder power and mean spherical equivalent (SE) also decreased significantly after ICL implantation. A small hyperopic shift in SE (+0.25 D) was observed at 2 years that did not alter visual outcomes. Conclusions. Visian toric ICL implantation following CXL is an effective option for improving visual acuity in patients with keratoconus up to 2 years.

Non-topography–guided PRK Combined With CXL for the Correction of Refractive Errors in Patients With Early Stage Keratoconus

PURPOSE To evaluate the safety and clinical outcome of combined non-topography-guided photorefractive keratectomy (PRK) and corneal collagen cross-linking (CXL) for the treatment of mild refractive errors in patients with early stage keratoconus. METHODS A retrospective, nonrandomized study of patients with early stage keratoconus (stage 1 or 2) who underwent simultaneous non-topography-guided PRK and CXL. All patients had at least 2 years of follow-up. Data were collected preoperatively and postoperatively at the 6-month, 1-year, and 2-year follow-up visit after combined non-topography-guided PRK and CXL. RESULTS Seventy-nine patients (140 eyes) were included in the study. Combined non-topography-guided PRK and CXL induced a significant improvement in both visual acuity and refraction. Uncorrected distance visual acuity significantly improved from 0.39 ± 0.22 logMAR before combined non-topography-guided PRK and CXL to 0.12 ± 0.14 logMAR at the last follow-up visit (P <.001) and corrected distance visual acuity remained stable (0.035 ± 0.062 logMAR preoperatively vs 0.036 ± 0.058 logMAR postoperatively, P =.79). The mean spherical equivalent decreased from -1.78 ± 1.43 to -0.42 ± 0.60 diopters (D) (P <.001), and the mean cylinder decreased from 1.47 ± 1.10 to 0.83 ± 0.55 D (P <.001). At the last follow-up visit mean keratometry flat was 43.30 ± 1.75 vs 45.62 ± 1.72 D preoperatively (P = .03) and mean keratometry steep was 44.39 ± 3.14 vs 46.53 ± 2.13 D preoperatively (P = .02). Mean central corneal thickness decreased from 501.74 ± 13.11 to 475.93 ± 12.25 µm following combined non-topography-guided PRK and CXL (P < .001). No intraoperative complications occurred. Four eyes developed mild haze that responded well to a short course of topical steroids. No eye developed infectious keratitis. CONCLUSIONS Combined non-topography-guided PRK and CXL is an effective and safe option for correcting mild refractive error and improving visual acuity in patients with early stable keratoconus.

Intravitreal anti-VEGF injection for the treatment of progressive juxtapapillary retinal capillary hemangioma: a case report and mini review of the literature

We report a case of a patient known to have a von Hippel–Lindau disease with documented progressive juxtapapillary retinal capillary hemangioma (JRCH) with well-preserved visual acuity (VA) and visual field (VF). The patient received a single injection of intravitreal ranibizumab (IVR). Six months after IVR injection, the JRCH showed reduced vascularization, fibrosis, and mild shrinkage, and VA and VF remained unchanged. IVR therapy might therefore be considered as an alternative treatment for progressive JRCH, especially in patients with well-preserved VA and VF.

Safety and efficacy of femtosecond laser–assisted arcuate keratotomy to treat irregular astigmatism after penetrating keratoplasty

Purpose To determine the refractive efficacy, predictability, stability, and complication rate of Intralase femtosecond laser–assisted astigmatic keratotomy (AK) for irregular astigmatism after penetrating keratoplasty (PKP). Setting Ophthalmology Department, Hôtel‐Dieu, Paris, France. Design Retrospective case series. Methods Femtosecond laser–assisted AK was performed to treat high irregular astigmatism (>5.0 diopters [D]) after PKP. The uncorrected (UDVA) and corrected (CDVA) distance visual acuities, manifest refraction, vector analysis, and complications were evaluated. Results The study evaluated 62 eyes of 57 patients over a mean follow‐up of 28 months ± 3.5 (SD). Preoperatively, the mean CDVA was 0.51 ± 0.26 logMAR and the mean UDVA was 0.98 ± 0.24 logMAR; 6 months postoperatively, the mean CDVA and UDVA improved to 0.40 ± 0.22 logMAR and 0.60 ± 0.2 logMAR, respectively (both P < .01). The mean preoperative absolute astigmatism was 7.1 ± 1.72 D; 6 months postoperatively, the mean refractive astigmatism was 2.6 ± 2.4 D (P < .001). The UDVA, CDVA, and astigmatism remained stable up to the end of follow‐up. The efficacy index was 0.81 at 6 months and 0.67 at 2 years. There were 2 cases of microperforation, 3 cases of infectious keratitis, 3 graft rejection episodes, and 1 case of endophthalmitis. Overcorrection occurred in 12 eyes. Conclusions Femtosecond laser–assisted AK was effective in reducing irregular astigmatism after PKP. Predictability of astigmatism correction is variable over time with a decrease in the efficacy index 2 years postoperatively. Refinement of the treatment nomogram for femtosecond laser–assisted AK for high astigmatism after PKP remains a major issue. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Corneal Infection Therapy with Topical Bacteriophage Administration

Staphylococcus aureus is a major pathogen in bacterial keratitis, a vision-threatening disease. Although the incidence of S. aureus keratitis varies worldwide, the increasing trend of resistance to certain antibiotics makes this condition an important, global, healthcare concern. We report the case of a 65-year-old woman with nosocomial left-eye corneal abscess and interstitial keratitis.The patient then undergo topical Phage therapy with successful results.

Non-topography-guided photorefractive keratectomy for the correction of residual mild refractive errors after ICRS implantation and CXL in keratoconus.

PURPOSE To evaluate the safety and clinical outcomes of non-topography-guided photorefractive keratectomy (PRK) for the treatment of residual mild refractive errors 6 months after sequential intracorneal ring segment (ICRS) implantation and corneal collagen cross-linking (CXL) in stable keratoconus. METHODS This retrospective study included 17 eyes of 14 patients with mild to moderate keratoconus. The ICRS implantation and CXL were performed sequentially with a 4-week interval and non-topography-guided PRK was performed at least 6 months after CXL. Data were collected preoperatively and at the 6-month follow-up visits. RESULTS ICRS implantation and CXL induced a significant decrease in keratometry and refraction and an increase in visual acuity. At the 6-month follow-up after ICRS implantation and CXL, uncorrected and corrected distance visual acuity (UDVA and CDVA) significantly improved from 1.17 ± 0.38 and 0.44 ± 0.09 logMAR preoperatively to 0.45 ± 0.11 and 0.17 ± 0.08 logMAR (P = .001) postoperatively, respectively. The mean spherical error decreased from -5.45 ± 1.64 to -2.57 ± 1.15 D (P = .01) and the mean cylinder from 3.86 ± 1.15 to 2.13 ± 1.11 D (P = .01). At the 6-month follow-up after PRK, UDVA significantly improved to 0.18 ± 0.06 logMAR and CDVA was 0.15 ± 0.05 logMAR. The mean spherical error and mean cylinder significantly decreased to -1.10 ± 0.41 D (P = .02) and 0.98 ± 0.37 D (P = .046), respectively. No intraoperative or postoperative complications occurred. CONCLUSIONS At the 6-month follow-up, non-topography-guided PRK after ICRS implantation and CXL was found to be an effective and safe option for correcting residual refractive error and improving visual acuity in patients with moderate keratoconus.

Pediatric Keratoconus in a Tertiary Referral Center: Incidence, Presentation, Risk Factors, and Treatment.

PURPOSE To report the incidence, clinical presentation, risk factors, and treatment outcome of pediatric keratoconus in a tertiary referral eye hospital in Beirut, Lebanon. METHODS In this retrospective study, the authors evaluated all patients with keratoconus 14 years or younger newly diagnosed at the Beirut Eye Specialist Hospital, Beirut, Lebanon, between January 2010 and December 2014. The incidence of pediatric keratoconus among all pediatric patients and among patients with keratoconus of all ages was assessed. Patients with pediatric keratoconus were evaluated for keratoconus stage, initial presentation, uncorrected distance visual acuity, corrected distance visual acuity (CDVA), corneal topography, and pachymetry. Patients were classified according to different treatment regimen groups and different follow-up visits were evaluated. RESULTS During 5 years, 16,808 patients were examined, of whom 2,972 were 14 years or younger. A total of 541 patients were diagnosed as having keratoconus; of those, 16 were 14 years or younger at the time of diagnosis. Hence, the incidence of keratoconus was 0.53% among pediatric patients and 3.78% among adult patients (> 14 years). Initial presentation was during routine checkup (1 of 16) for allergic conjunctivitis (3 of 16), reduced vision (10 of 16), and corneal hydrops (mimicking keratitis) (2 of 16). Except for 2 patients lost to follow-up, all eyes received corneal cross-linking treatment and 16 eyes received additional intracorneal ring segment implantation. CONCLUSIONS The incidence of pediatric keratoconus indicates that increased awareness for keratoconus among children is needed, mainly in cases of family history of keratoconus, ocular allergy/pruritus, poor CDVA, corneal hydrops, and/or high astigmatism. [J Refract Surg. 2016;32(8):534-541.].

Rate of Corneal Collagen Crosslinking Redo in Private Practice: Risk Factors and Safety

Objective. To report the rate of progression of keratectasia after primary crosslinking (CXL) and evaluate the safety and efficiency of CXL redo. Materials and Methods. We conducted a retrospective analysis of the patients who underwent CXL between 2010 and 2013 at the Beirut Eye Specialist Hospital, Lebanon. Progression of keratectasia was based on the presence of an increase in maximum keratometry of 1.00 D, a change in the map difference between two consecutive topographies of 1.00 D, a deterioration of visual acuity, or any change in the refraction. Primary and redo CXL were done using the same protocol. Results. Among the 221 eyes of 130 patients who underwent CXL, 7 eyes (3.17%) of five patients met the criteria of progression. All patients reported a history of allergic conjunctivitis and eye rubbing and progressed within 9 to 48 months. No complications were noted and all patients were stable 1 year after CXL redo. Conclusion. Allergic conjunctivitis and eye rubbing were the only risk factors associated with keratoconus progression after CXL. A close followup is thus mandatory, even years after the procedure. CXL redo seems to be a safe and efficient technique to halt the progression after a primary CXL.