Elise Slim

VITREORETINAL SURGERY WITH SILICONE OIL TAMPONADE IN PRIMARY UNCOMPLICATED RHEGMATOGENOUS RETINAL DETACHMENT: Clinical Outcomes and Complications.

Background: To determine the anatomical and functional outcomes and possible complications after pars plana vitrectomy (PPV) with silicone oil (SO) tamponade in primary uncomplicated rhegmatogenous retinal detachments. Methods: This is a prospective observational study. Overall, 62 consecutive patients who underwent surgical repair by PPV and SO injection for primary uncomplicated rhegmatogenous retinal detachment between January 01, 2006 and April 30, 2012 were followed. In general, PPV was chosen over scleral buckling when a significant cataract or a vitreous hemorrhage prevented adequate fundus visualization. Silicone oil was chosen over gas tamponade in patients living at 1,000 meters above the sea level, where SF6 or C3F8 tamponade could not be performed because of the risk of acute increase of intraocular pressure (IOP). One thousand centistokes SO was used in all eyes. At all visits, patients had a detailed ocular history and thorough bilateral evaluation, including best-corrected visual acuity, anterior segment examination, and IOP measurements by aplanation and fundus examination. Outcomes were assessed at 1 day, 1 week, 1 month, 3 months, 6 months, and every 6 months thereafter. Increased IOP was defined as an IOP of more than 21 mmHg. Results: Anatomical success rate, final best-corrected visual acuity, IOP elevation, cataract formation, and other complications were the main outcome measures. This study included 62 eyes of 62 patients (41 men and 21 women) that underwent retinal detachment repair by PPV and SO injection. The age at the time of intervention was 57.6 ± 10.5 years (mean ± standard deviation; range, 34–79 years). All patients were whites. Mean follow-up was 24.5 ± 17.3 months (range, 6–70 months). Anatomical success rate defined as retinal reattachment 6 months after SO removal was 93.5%. Final BCVA was improved in 55 eyes (88.7%), with a mean of 4 Snellen lines, unchanged in 5 (8.1%), and worse in 2 eyes (3.2%), with a mean of 3 Snellen lines. Mean duration of SO tamponade was 5.12 ± 2.37 months (range, 2–12 months). From the 30 eyes that were still phakic after vitrectomy, 24 eyes (80.0%) underwent cataract surgery within a period of 7.37 ± 3.00 months (range, 2–13 months). Thirty-five eyes (56.5%) had an increase in IOP during the follow-up period. Thirty-one patients had transient ocular hypertension requiring topical treatment during the immediate postoperative period (one month). Only 1 eye (2.9%) required filtrating drainage surgery for IOP control. No eyes developed optic neuropathy secondary to IOP elevation. Conclusion: Pars plana vitrectomy with SO injection seems to be a safe and efficient surgical approach in the treatment of primary uncomplicated rhegmatogenous retinal detachment in patients living in high altitude (>1,000 m). Also, PPV and SO injection are associated with good anatomical and functional outcomes in our series. Reattachment rates are high, and rates of proliferative vitreoretinopathy are low. Cataract formation and elevated IOP represent frequent but successfully controlled complications.

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.

Effect of hemodialysis on visual acuity, intraocular pressure, and macular thickness in patients with chronic kidney disease.

Background The aim of this study was to evaluate the effects of hemodialysis (HD) on visual acuity, intraocular pressure (IOP), and central foveal thickness (CFT) in patients with chronic kidney disease. Materials and methods Forty-nine eyes from 49 chronic kidney-disease patients were analyzed. Causes of chronic kidney disease included diabetes mellitus (n=9 patients), hypertensive nephrosclerosis (n=15 patients), and other causes (n=25 patients). All patients underwent HD in the Dialysis Unit of Hôtel-Dieu de France Hospital. Best-corrected visual acuity, CFT, and IOP were evaluated before and after HD. CFT was measured with spectral domain optical coherence tomography, and IOP was measured with Goldmann applanation tonometry. Results Neither decimal best-corrected visual acuity (pre-HD 0.71±0.32, post-HD 0.72±0.31; P=0.877) nor CFT (pre-HD 251.39±39.29, post-HD 253.09±39.26; P=0.272) significantly changed after HD. However, mean IOP significantly decreased from 13.99±2.48 before HD to 12.65±2.41 mmHg after HD (P=0.001). IOP change was significantly correlated with serum albumin levels (P=0.008) and weight changes (P=0.047). Conclusion HD can affect various ocular parameters. This is particularly true of IOP, which decreases significantly following HD.

Intravitreal bevacizumab for retinal capillary hemangioblastoma: A case series and literature review

OBJECTIVE To evaluate the long-term outcomes of intravitreal bevacizumab for peripheral and juxtapapillary retinal capillary hemangioblastoma (RCH). DESIGN We conducted a retrospective noncomparative interventional case series. PARTICIPANTS There were 4 patients (5 eyes) presenting with RCH. METHODS Five eyes with RCH presented with exudative changes and visual loss. Three eyes of 2 patients with peripheral RCH were treated with cryotherapy and 2 intravitreal injections of bevacizumab (0.5 mg). Two eyes with juxtapapillary RCH were treated with 3 intravitreal injections of bevacizumab. The main outcome measures were changes in best-corrected visual acuity (BCVA), lesion size, exudation, and retinal thickness. RESULTS In peripheral RCH, improvement of BCVA from counting fingers to 20/400 was obtained in 1 eye. One patient with bilateral RCH maintained a vision of 20/20 in 1 eye with complete anatomic regression of the 3 small peripheral RCH lesions. The fellow eye with fibrotic bands from the RCH to the optic nerve head developed a tractional retinal detachment after the first injection and was treated with pars plana vitrectomy. In patients with juxtapapillary RCH, bevacizumab injections resulted in an improvement of BCVA from 20/80 to 20/20 in 1 eye, whereas the second eye did not show an improvement of BCVA despite a regression of the tumour. CONCLUSIONS Intravitreal anti-vascular endothelial growth factor agents, alone or in combination with other treatment modalities, may improve visual acuity. Further trials evaluating the dose, the number of injections, and the route of administration will be important in advancing antiangiogenic therapies for RCH.

Idiopathic central retinal artery occlusion in an eight-year-old girl.

Central retinal artery occlusion (CRAO) is extremely rare in the pediatric population. The incidence of CRAO in patients under the age of 30 has been estimated at less than 1 in 50,000 outpatients; however, this number is much lower in patients under the age of 10 [1]. Many predisposing factors to embolic phenomena leading to CRAO in children have been reported, such as mitral valve prolapse, rheumatic heart disease, atrial myxomas, orbital trauma, collagen vascular diseases, sickle cell disease, neoplastic disorders, homocystinuria, factor V Leiden mutations, anticardiolipin antibody, herpes zoster ophthalmicus, and varicella infections [2]. Central retinal artery occlusion has also been described after ocular surgery or periocular anesthesia [3]. In rare instances, none of the aforementioned causes is found and the CRAO is considered idiopathic. We report an idiopathic central retinal artery occlusion in an eightyear-old girl whose vision rapidly deteriorated to no light perception. An eight-year-old girl was referred to our department by her pediatrician when she presented to him on the same day of an acute painless acute unilateral blindness in her right eye (RE). She had no known previous medical problems except for a single episode of urinary tract infection (UTI) at the age of three treated with oral sulfamethoxazole and trimethoprim syrup for one week. The vaccination schedule was up to date. The child had normal weight to age ratio, and had no history of renal disease, diabetes. Family history was negative for stroke, myocardial infarction, or multiple spontaneous miscarriages in females. Ocular examination revealed a visual acuity of no light perception (NLP) in her RE and 20/20 in the left eye (LE) with afferent pupillary defect (RAPD) in the aforementioned eye. Oculomotricity was normal. The anterior segment exam was normal in both eyes. The fundus examination of her RE showed RE showed diffuse retinal edema centered in the posterior pole, with a swollen optic nerve, arteriolar attenuation and a cherry red spot at the fovea, suggestive of central retinal artery occlusion (CRAO) (Fig. 1). The fundus exam of the LE was normal. F r luorescein angiography showed significant enlargement of he foveal avascular zone of the RE (with masking effect ue to retinal edema), a delay in the retinal arterial filling, s well as delay in the arteriovenous transit time (Fig. 2). o other signs of vascular disease was found in the periphry or the fellow eye. OCT findings were consistent with he diagnosis showing thickening and increased reflectivity f the inner retinal layers with shadowing effect on outer tructures (Fig. 3). The patient’s general status including a complete physial exam was normal as per her pediatrician. Extensive workup was rapidly conducted. Blood investiations, including her blood pressure, heart rate, glucose, ipid, and coagulation profiles, as well as her erythrocyte edimentation rate and C-reactive protein were noral. Peripheral blood smear, prothrombin/activated partial hromboplastin time (PT/PTT), serum lipids, autoimmune arkers (antinuclear, anticardiolipin, antiphospholipid), ntineutrophilic cytoplasmic (ANCA) antibodies, hypercogulability testing including fibrinogen, antithrombin III, roteins C and S, factor V Leiden assay, activated protein (APC) resistance test, and serum homocysteine was negtive. Infectious disease workup revealed a negative PPD est and negative quantiferon gold levels, titers of Toxo-

Toric ICL Implantation After Sequential Intracorneal Ring Segments Implantation and Corneal Cross-linking in Keratoconus: 2-Year Follow-up.

PURPOSE To evaluate 6-month and 2-year safety and clinical outcomes of Visian toric Implantable Collamer Lens (toric ICL) (STAAR Surgical, Monrovia, CA) implantation for the treatment of residual refractive errors after sequential intracorneal ring segments (ICRS) insertion and cross-linking (CXL) in keratoconus. METHODS This consecutive case series included the results of a three-step ICRS-CXL-toric ICL procedure in 16 eyes of 13 patients with moderate to severe keratoconus (stages II and III of Amsler-Krumeich classification). The ICRS and CXL procedures were performed sequentially with an interval of 4 weeks and the toric ICL implantation was performed at least 6 months after CXL. Data were collected preoperatively, at 6 months after sequential ICRS-CXL, and at 6 and 24 months following toric ICL implantation. All 16 eyes were evaluated at the 2-year follow-up. RESULTS There was a significant decrease in keratometry (steep, flat, and maximum) and refraction (sphere and spherical equivalence, but not cylinder) and a significant increase in both uncorrected (UDVA) (from 1.06 to 0.76 logMAR, P = .004) and corrected (CDVA) (from 0.42 to 0.26 logMAR; P = .002) distance visual acuity 6 months following sequential ICRS-CXL, whereas UDVA and refraction significantly improved 6 months after ICL insertion (UDVA reached 0.33 logMAR, P = .001). At the 24-month follow-up, UDVA and keratometric readings were stable, whereas CDVA, sphere, and cylinder showed a significant improvement. CONCLUSIONS Implantation of Visian toric ICL following sequential ICRS insertion and CXL is an effective and safe option for correcting high residual refractive error and improving visual acuity in patients with moderate to severe keratoconus in the long term. [J Refract Surg. 2017;33(9):610-616.].

Secondary intraocular lens implantation with absence of capsular support: Scleral versus iris fixation

PURPOSE To assess the outcomes of iris fixated (IF) posterior chamber (PC) intraocular lens (IOL) versus scleral-fixated (SF) PC IOL implantation, and compare them with the results reviewed from the literature. SETTING The study took place in the ophthalmology department of the Eye and Ear Hospital (Lebanon). DESIGN This is a retrospective institutional study that collected the records of patients admitted for secondary IOL implantation between January 2007 and December 2016. METHODS A total of 28 eyes that underwent PC IOL fixation were included, 13 of which underwent trans-scleral PC IOL fixation and 15 of which underwent iris PC IOL fixation. Data were analyzed over a period of 3 years. RESULTS Of the 28 patients, 18 (64.3%) were male and 10 (35.7%) were female (mean age at intervention 36.78±23.47 [standard deviation, SD] years). There were no significant intergroup differences with regard to baseline values and demographic characteristics. Trauma was the most common etiology for posterior capsule insufficiency (82.1%). The mean preoperative baseline BCVA was 0.58±0.27 logMAR for SF and 0.27±0.20 logMAR for IF (P=0.07). Both groups had significant improvement in vision during the follow up period. No significant differences were noted regarding early or late postoperative complications between the two groups. CONCLUSION SF and IF techniques for PC IOL have similar outcomes and result in a significant improvement in BCVA. When compared to AC (anterior chamber) IOL, both techniques seem to yield fewer complications.

Thick keratoconic cornea associated with posterior polymorphous corneal dystrophy

INTRODUCTION We herein report a case of bilateral unusually thick non-edematous keratoconic corneas with associated endothelial features of posterior polymorphous corneal dystrophy (PPCD). CASE REPORT We report the case of a 27-year-old myopic woman who presented for refractive surgery. Slit lamp exam showed bilateral corneal protrusion with diffuse deep stromal and endothelial vesicular opacities and small paracentral bands. Topography showed generalized advanced corneal steepening in both eyes with increased anterior and posterior central corneal elevations in comparison to the best fit sphere. Ultrasound pachymetry showed central corneal thickness of 605μm (RE) and 612μm (LE). On specular biomicroscopy, cell density of 2503 cells/mm2 RE and 1526 cells/mm2 LE with significant cellular pleomorphism and polymegathism were noted. DISCUSSION Clinical and paraclinical findings together suggest the presence of simultaneous keratoconus and PPCD. The literature has suggested an association between PPCD and steep cornea. Moreover, many reports have also described cases of associated PPCD and keratoconus with characteristic thinning and ectasia, in comparison to the unusual thick corneas noted in our patient, despite the absence of edema. Identification of genetics factors is further needed to clarify this association. CONCLUSION This case describes a patient whose corneas present features of both keratoconus and PPCD and is unique due to the presence of increased corneal thickness despite the absence of edema.

Dépistage de la Rétinopathie et de la Maculopathie Diabétique au Liban par Rétinographie et par SD - OCT : Intérêt de la Télémédecine

Le diabète sucré (DM) est une maladie chronique qui exige des soins médicaux continus et une éducation des patients pour minimiser les complications liées à cette maladie. La rétinopathie diabétique (RD) est l’une des complications microangiopathiques les plus fréquentes chez les diabétiques [1] et elle constitue la première cause de cécité dans les pays développés avant l’âge de 65 ans et la deuxième cause après l’âge de 65 ans [2]. Le fardeau de la RD augmente avec l’augmentation de la prévalence du diabète (surtout le diabète de type 2), notamment dans les pays du Moyen-Orient, où la prévalence du diabète de type 2 a été estimée à 15,8% chez les sujets âgés de plus de 40 ans [3]. Au Liban, la prévalence de la RD est évaluée à 17% selon une étude de dépistage dans la population libanaise [4] et à 35% selon une étude menée dans un hôpital universitaire de Beyrouth [5]. Les recommandations actuelles préconisent de faire au moins un examen ophtalmologique annuel avec un fond de l’œil à la recherche de la RD chez tous les patients diabétiques de type 2 [6]. Néanmoins, une proportion importante de sujets diabétiques ne bénéficie pas d’un examen ophtalmologique annuel. La stratégie optimale pour le dépistage de la RD reste