Haytham I. Salti

Bone marrow mesenchymal stem cell transplantation in patients with multiple sclerosis: A pilot study☆

We explore the safety, and therapeutic benefit of intrathecal injection of ex-vivo expanded autologous bone marrow derived mesenchymal stem cells (BM-MSCs) in 10 patients with advanced multiple sclerosis (MS). Patients were assessed at 3, 6 and 12 months. Assessment at 3-6 months revealed Expanded Disability Scale Score (EDSS) improvement in 5/7, stabilization in 1/7, and worsening in 1/7 patients. MRI at 3 months revealed new or enlarging lesions in 5/7 and Gadolinium (Gd+) enhancing lesions in 3/7 patients. Vision and low contrast sensitivity testing at 3 months showed improvement in 5/6 and worsening in 1/6 patients. Early results show hints of clinical but not radiological efficacy and evidence of safety with no serious adverse events.

Ethmoid sinus osteoma presenting as epiphora and orbital cellulitis: case report and literature review.

Paranasal sinus osteoma is a slow-growing, benign, encapsulated bony tumor that may be commonly asymptomatic, being detected incidentally in 1% of plain sinus radiographs or in 3% of sinus computerized tomographic scans. In a patient presenting with orbital cellulitis and epiphora, computed tomography disclosed a large osteoma of the ethmoid sinus. Excision of the osteoma allowed recovery of vision, return of extraocular muscle function, and resolution of choroidal folds. Proptosis, diplopia, and visual loss are other frequent presenting signs of paranasal osteomas. Epidemiology, diagnosis, treatment, and pathologic findings in paranasal sinus osteoma are reviewed.

Ocular Findings in Aplastic Anemia

Objective: To analyze the ocular findings in aplastic anemia. Design: Eighteen patients with aplastic anemia were examined. Results: Ocular findings included cotton wool spots (38%), nerve fiber layer or preretinal hemorrhages (67%), vitreous hemorrhages (13%), a picture resembling central retinal vein occlusion (13%) and optic disk edema (6%). Preretinal hemorrhages were the presenting sign of aplastic anemia in 2 patients (13%). Conclusions: A blood profile is needed in patients with unexplained retinal hemorrhages. Patients with aplastic anemia need to avoid ocular massage and Valsalva maneuvers to decrease ocular morbidity.

Ranibizumab monotherapy versus single-session verteporfin photodynamic therapy combined with as-needed ranibizumab treatment for the management of neovascular age-related macular degeneration.

Purpose: To compare verteporfin photodynamic therapy combined with intravitreal ranibizumab (combination therapy) versus ranibizumab monotherapy for management of neovascular age-related macular degeneration. Methods: Thirty patients (40 eyes) with neovascular age-related macular degeneration were prospectively allocated to combination therapy or monotherapy. In monotherapy, the induction phase consisted of 3 consecutive monthly ranibizumab injections (0.5 mg), while the combination therapy had a single session of photodynamic therapy with intravitreal ranibizumab. Follow-up treatment for either group consisted only of additional as-needed ranibizumab injections. The main outcome measure was that a proportion of eyes losing <15 letters of visual acuity after 12 months. Results: Except for 1 eye in combination therapy, all eyes in both groups lost <15 letters of visual acuity. At 12 months, there was a mean gain of +12 letters and +3.2 letters for monotherapy and combination therapy, respectively (relative percent change of 32% vs. 7%, P = 0.03). Anatomical improvement was similar in both groups. After induction, the time until ranibizumab retreatment was longer for combination therapy (P = 0.002) while ranibizumab injections were required more frequently with monotherapy (P = 0.015). Conclusion: Ranibizumab monotherapy showed greater improvement in visual acuity versus combination therapy. However, combination therapy required fewer ranibizumab injections. Larger trials need to confirm the findings of this pilot study.

DICOM transmission of simultaneous stereoscopic images of the optic nerve in patients with glaucoma.

We evaluated the Digital Imaging and Communications in Medicine (DICOM) standard for the transmission of stereoscopic images of the optic nerve. Digital optic nerve images were obtained from patients with glaucoma. Fifteen simultaneous stereo images from consecutive patients were analysed independently twice, in random order, by two glaucoma specialists to establish baseline values of vertical and horizontal cup-to-disc (CDV and CDH) ratios and image quality (1 = worst, 5 = best). Images were transmitted to a distant location and returned to the sending site using DICOM standards in both directions. The received images were reassessed again by the two glaucoma specialists. The image file size slightly increased for all received images (mean 2545 kByte) in comparison with the transmitted images (mean 2460 kByte). The mean baseline values for CDV, CDH and quality score were 0.66, 0.59 and 3.9, respectively. The corresponding mean values for the received images were 0.66, 0.62 and 3.73, respectively. The differences between transmitted and received images were not significant. Clinical interpretation of digital stereoscopic images of glaucomatous optic nerves appears to be unaffected by DICOM capture and transmission.

Fixed-interval versus OCT-guided variable dosing of intravitreal bevacizumab in the management of neovascular age-related macular degeneration: a 12-month randomized prospective study.

PURPOSE To compare the efficacy of as-needed or variable dosing of intravitreal bevacizumab to continuous fixed-interval dosing in the management of neovascular age-related macular degeneration (AMD). DESIGN Prospective, open-label, randomized clinical study. METHODS One hundred twenty eyes of 120 patients with treatment-naïve subfoveal neovascular AMD participated in this study at the American University of Beirut and Hotel Dieu de France Retina Clinics. Eyes were randomized (1:1) to fixed-interval dosing (every 4 to 6 weeks) or variable dosing with intravitreal bevacizumab (1.25 mg/0.05 mL). Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) using optical coherence tomography (OCT) were measured at baseline and at each follow-up visit. Presence or recurrence of fluid on OCT was the main indicator for retreatment in variable dosing. Main outcome measure was improvement in BCVA and CRT at 12 months. RESULTS Compared to baseline, variable dosing had a mean improvement in BCVA of 11.0 letters after 12 months vs 9.2 letters for fixed-interval dosing (P = .81). Similarly, CRT decreased after 12 months by 80.7 μm for variable dosing vs 100.5 μm for fixed-interval dosing (P = .37). The average number of injections over 12 months was higher for fixed-interval dosing than variable dosing (9.5 vs 3.8 injections, P < .001). CONCLUSIONS Fixed-interval and variable dosing regimens of intravitreal bevacizumab improved visual acuity and anatomic outcomes after 12 months in eyes with neovascular AMD. However, variable dosing had a reduced treatment burden. Larger trials are needed to confirm these results.

Prevalence and determinants of retinopathy in a cohort of Lebanese type II diabetic patients

OBJECTIVE Our aim was to determine the prevalence and the risk factors for diabetic retinopathy (DR) in a cohort of type II diabetic patients in Lebanon. DESIGN Prospective observational cohort study. PARTICIPANTS Five hundred consecutive patients with type II diabetes mellitus followed at the American University of Beirut Medical Center diabetes clinic were enrolled in the study. METHODS All patients 18 years or older with diabetes mellitus who did not have gestational diabetes and who were able to complete the laboratory data and the retinal examination were invited to participate in the study; they were followed up for a period of 3 years. RESULTS DR was present in 175 patients (35%), 130 (26%), and 45 (9%) having nonproliferative and proliferative DR, respectively. Clinically significant macular edema was present in 42 patients (8%). Microvascular and macrovascular diabetic complications, duration of disease, glycemic control, presence of hypertension (p < 0.003), systolic blood pressure (p = 0.04), and insulin use (p < 0.001) were individually significantly associated with a higher prevalence of DR on bivariate analysis. However, on multivariate regression analysis, only glycosylated hemoglobin >7% (odds ratio [OR] 2.81, 95% CI 1.06-7.43, p = 0.038), duration of diabetes (per 10 years, OR 9.0, 95% CI 4.0-20.0, p < 0.001), macroalbuminuria (OR 2.6, 95% CI 1.14-5.96 p = 0.023), and systolic blood pressure (per 10 mm Hg, OR 1.27, 95% CI 1.0-1.56, p = 0.037) were independent risk factors for DR. CONCLUSIONS The elevated prevalence of DR in type II diabetic patients with high risk profiles calls for early medical intervention and education about DR and its identified controllable risk factors.

Vascular complications of diabetes in Lebanon: Experience at the American University of Beirut

Aim To examine the metabolic control and presence ofcomplications, among a cohort of diabetic patients in Lebanon. Method A total of 313 diabetic patients presenting for their usual care were screened in a cross-sectional manner for metabolic control and presence of complications at the American University of Beirut.Results Only 235 subjects completed their data of whom 220 (93%) had type 2 diabetes with mean duration of disease of 8.2 (±6.6) years. Only 30% had haemoglobin A1C < 7%, and 35.5% had low-density lipoprotein Cholesterol < 2.6 mmol/L. About 50.5% were obese, 34.9% current smokers, and 40.7% had blood pressure ≥ 140/90 mmHg. Microvascular complications were present as 46.3, 39.9 and 33% for albuminuria, neuropathy, 33% for albuminuria, neuropathy, and retinopathy, respectively. Macrovascular complications were as follows: 19.3, 18.3 and 4.1% for coronary artery disease, peripheral vascular disease and cerebrovascular disease, respectively.Conclusions This study highlights the poor control and h...

Nonmydriatic Retinal Image Review at Time of Endocrinology Visit Results in Short-Term HbA1c Reduction in Poorly Controlled Patients with Diabetic Retinopathy

OBJECTIVES The objective of this study was to evaluate the effect of discussing retinal findings following nonmydriatic retinal imaging during an endocrinology visit on subsequent HbA1c in poorly controlled diabetic patients with diabetic retinopathy (DR). MATERIALS AND METHODS During a visit to an endocrinologist, patients with DR and documented HbA1c ≥ 8.0% within the preceding month were assigned to either addition of nonmydriatic imaging and discussion of retinal findings or standard endocrinology evaluation alone. Ophthalmology care was otherwise the same in both groups. Changes in HbA1c were evaluated 3 months later. RESULTS One hundred thirteen (94%) of the original 120 subjects completed the study. The mean HbA1c change in the retinal imaging group was a decline of 1.35%, whereas the control group had a 0.26% increase. Controlling for gender, age, duration of diabetes, presence of hypertension, and use of insulin, the difference between groups was significant (p<0.0003). CONCLUSIONS Nonmydriatic imaging and discussion of retinal findings during an endocrinologist visit may contribute, at least in the short term, to improved glycemic control in patients with DR and elevated HbA1c.

Impact of AREDS in a developing country 5 years after publication of the study.

Purpose The Age-Related Eye Disease Study (AREDS) is the only large-scale study to demonstrate a reduction in the risk of progression to end-stage age-related macular degeneration (AMD) when vitamin supplementation was given to patients with advanced forms of the disease. Our study assesses the impact of this study on vitamin supplementation in patients with advanced AMD from 5 years before publication of the AREDS results until 5 years after. Methods Medical records of patients with AMD presenting between September 1996 and October 2006 were reviewed. Patients were subclassified according to AREDS categories. The proportion of advanced cases on vitamin replacement before October 2001 was compared to that after October 2001. Since October 2001, the different reasons for abstinence were investigated and analyzed. Results Only 2403 patients of the 40,000 medical records reviewed met the AREDS AMD criteria. Of these, 137 patients verifying categories 3 and 4 were diagnosed prior to October 2001. Fourteen were on supplements then. Fifty-three patients complied with the represcribed vitamins during subsequent visits after October 2001, raising the percentage significantly to 48.9% (p<0.001). Also, from October 2001 until October 2006, an additional 76 patients verified categories 3 and 4. Fifty-three (69.7%) of them were on vitamins (p=0.001). Financial burden was the principal reason for abstinence in 67.7% of patients prescribed vitamins after October 2001. Conclusions The results of AREDS had an impressive impact on prescribing supplements in AREDS category 3 and 4 patients in Lebanon. The main reason for noncompliance is financial.