Sulaiman M. Alsulaiman

Pars plana vitrectomy with juxtapapillary laser photocoagulation versus vitrectomy without juxtapapillary laser photocoagulation for the treatment of optic disc pit maculopathy: the results of the KKESH International Collaborative Retina Study Group

Background/aims To compare the functional and anatomic outcomes of pars plana vitrectomy (PPV) with juxtapapillary laser photocoagulation (JLP) versus vitrectomy without JLP in optic disc pit maculopathy. Methods This was a multicentre, retrospective study of 46 consecutive patients with optic disc pit maculopathy presenting at tertiary eye centres between 1992 and 2012. Indications for surgery included distorted or decreased vision. Surgical intervention included PPV, posterior vitreous detachment, with or without gas tamponade. Twenty-four patients received laser photocoagulation at the temporal edge of the optic disc pit (group A) and 22 patients had no laser (group B). Postoperative best-corrected visual acuity (BCVA) and optical coherence tomography findings were the main outcome measures. Results Mean follow-up was 44 months (range 12–98 months). BCVA in group A improved significantly from 0.7 logMAR (20/100) preoperatively to 0.5 logMAR (20/60) postoperatively (p=0.017). In group B, BCVA improved from 0.7 logMAR (20/100) preoperatively to 0.4 logMAR (20/40) postoperatively (p=0.014). The difference in final BCVA between groups was not statistically significant (p=0.693). The mean central macular thickness (CMT) in group A improved significantly from 750 μm preoperatively to 309 μm at last follow-up (p<0.0001). The mean CMT in group B improved from 616 μm preoperatively to 291 μm at last follow-up (p=0.028). The difference in final CMT between groups was not statistically significant (p=0.747). Conclusions PPV with JLP for optic disc pit maculopathy had similar functional and anatomic outcomes compared with vitrectomy without JLP.

Ocular injuries secondary to alexandrite laser-assisted hair removal

PURPOSE The aim of this study was to describe the clinical manifestations and outcomes of 4 patients who had sustained eye injury during alexandrite laser-assisted hair removal. METHODS This was a retrospective case series of 4 patients who presented to 2 tertiary eye care hospitals over 2 years. Data on ophthalmic examination, spectral domain optical coherence tomography (Heidelberg Engineering, Heidelberg, Germany), and fundus fluorescein angiography were collected. RESULTS Four female patients sustained injuries during alexandrite laser hair removal. One patient presented with acute anterior uveitis, 2 patients with subfoveal choroidal neovascularization, and 1 patient with intraretinal foveal hemorrhage. Visual acuity at last follow-up (range 3-6 months) was 20/15 to 20/20. CONCLUSIONS Ocular injuries can occur as a result of incorrect use of laser-assisted hair removal devices. Ophthalmologists should be aware of ocular damage caused by these devices.

Incidence of Endophthalmitis after Intravitreal Anti-vascular Endothelial Growth Factor: Experience in Saudi Arabia.

Purpose: To report the incidence of endophthalmitis, the clinical and microbiological aspects, after intravitreal (IVT) injection of anti-vascular endothelial growth factor. Methods: A chart review was performed of patients diagnosed with endophthalmitis after receiving IVT injections of bevacizumab (Avastin) and ranibizumab (Lucentis) presenting to King Khaled Eye Specialist Hospital (KKESH) from May 2006 to December 2012. Endophthalmitis was diagnosed clinically as an intraocular infection with vitreous involvement that required treatment with IVT antibiotics or had undergone pars plana vitrectomy (PPV) to remove the suspected microorganism. Main outcome measures were the incidence of endophthalmitis and the clinical and microbiological features. Results: Seven cases of endophthalmitis were identified, there was 1 (0.004%) case of endophthalmitis of 22674 IVT injections performed at KKESH. All cases were after IVT bevacizumab. Three (42.85%) cases were culture-positive and caused by Staphylococcus epidermidis. The initial management was vitreous tap and IVT injection of antibiotics followed by PPV in 6 (85.7%) cases. One (14.3%) case underwent evisceration. Visual acuity improved at last visit in only 2 (28.6%) cases. The rate of endophthalmitis was 0.0004% for bevacizumab. Conclusions: The rate of endophthalmitis after IVT bevacizumab and ranibizumab was very low. We recommend following a standardized injection protocol, adherence to sterile techniques, and proper patient follow.up are determinant factors for low incidence rates. In addition, endophthalmitis after IVT bevacizumab and ranibizumab have poor visual outcomes despite prompt treatment.

Combined cilioretinal artery and hemi-retinal vein occlusion in Sturge Weber syndrome: Expanding the clinical spectrum

A 9-year-old boy with the diagnosis of Sturge-Weber Syndrome, and port-wine stain involving the right side of the face, presented with acute visual loss of the right eye. Examination revealed a high intraocular pressure and a combined cilioretinal artery and inferior hemi-retinal vein occlusion in the right eye. Systemic work-up was negative. After controlling the intraocular pressure, gradual improvement of vision was noticed with simultaneous disappearance of signs of vascular occlusion.

Anterior Segment Injury by a High-Power Handheld Blue Laser Device

ABSTRACT Purpose: To report a case of severe anterior segment inflammation secondary to exposure to a high-power blue laser device. Methods: Case report. Results: A 14-year-old male presented with redness, pain and decreased vision in his left eye after exposure to blue laser. Examination indicated severe conjunctival injection associated with 4+ cells in the anterior chamber with fibrinous reaction. The posterior pole was normal. Conclusion: Blue laser devices are easily available through the Internet. These devices can cause devastating ocular injuries. National safety guidelines are required to regulate use.

Laser pointers: how much does the general medical community know?

To the Editor: In the last several years, laser pointer-related eye injuries have been increasing. The wave started after the manufacture of highly powered laser pointers that resemble the legally available low power (<5 mW) pointers and following their availability at a low cost. Several studies reported various retinal laser injuries including outer foveal disruption, full thickness macular hole, epiretinal membrane, retinal hemorrhage, and choroidal neovascularization [1–4]. Some of these manifestations required surgical intervention, and some caused permanent visual loss. Since physicians commonly use laser pointers and are at risk of mistakenly obtaining a high-power pointer instead, we sought to assess their awareness about the ocular hazards of laser pointers. A cross sectional, international, internet-based anonymous survey of 11 questions (supplementary document) was distributed via email and social media to physicians in various specialties and optometrists. One hundred and three (35.6%) respondents were ophthalmologists, 128 (44.1%) were internists, 30 (10.3%) were surgeons, and 18 (6.2%) were optometrists. The following significant findings were noted: First, 194 (67%) participants use laser pointers during lectures. The pointers were self-owned in 46% of them. Ophthalmologists were more likely to use laser pointers during lectures [73 of 96 (73%)] compared to nonophthalmologists [121 of 194 (62.4%)]; (P = 0.02). Out of these 194 participants, 159 (82%) did not know the power of the pointer they use and 80% never checked its power before using it. Second, 263 (90.7%) respondents did not know the power limit below which the pointer is considered safe. Only 168 of 290 (58%) respondents thought that laser pointers are not safe as far as the eye is concerned while 75 (26%) respondents thought they are, and 47 (16%) did not know if pointers are safe or not. Third, only174 (66%) participants were aware of the availability of high-power pointers at low cost. Fourth, ophthalmologists were more likely to know the safety threshold (P = 0.008), to be aware of the availability of high-power pointers at low cost (P = <0.0001), and to know some of the hazards of laser pointers (P = <0.0001). While larger studies are needed to prove these results, the findings of this survey suggest that we as physicians lack sufficient knowledge regarding laser pointer hazards and safe laser power limits. Besides the associated hazard, since strict regulatory governmental measures and international awareness campaigns, which most likely will involve physicians, are needed to combat the potential public hazard that high-power laser pointers pause, improved physician knowledge of laser basics seems critical.

Intraretinal macular hemorrhage due to high-power handheld blue laser

A 22-year-old male experienced immediate visual loss in his left eye after momentary blue laser exposure from 1-m distance. The power and wavelength of the device were 5000 mW and 445 nm based on the label, respectively. On examination, the best-corrected visual acuity (BCVA) was 20/20 OD and 20/200 OS. Intraocular pressure was 12 mm Hg in both eyes. Anterior segment examination of both eyes and right eye fundus examination were normal. Fundus examination of the left eye showed a small white burn surrounded by intraretinal blood superonasal to the fovea. Furthermore, the blood appeared to extend into the foveal area within the outer layers of the retina (Fig. 1). Spectral-domain optical coherence tomography (OCT) (Spectralis HRA; Heidelberg Engineering, Heidelberg, Germany) at the injury site showed a full-thickness intraretinal hyper-reflective lesion with a width that tapered toward the outer layers (Fig. 2A). Spectral-domain OCT cross section through the fovea showed a mound of hyperreflective lesion mainly at the level of the outer plexiform and nuclear layers (Fig. 2B). Spectral-domain OCT at 3 weeks showed resolution of the mound with restoration of the foveal contour along with a wide hyper-reflective vertical cone extending into the ellipsoid zone (Fig. 2C). Within 5 weeks of observation, BCVA improved to 20/40 with resolution of the blood on fundus examination.

Retinal Detachment in Down Syndrome: Characteristics and Surgical Outcomes

Purpose. To determine the functional and anatomic outcomes of rhegmatogenous retinal detachment (RRD) surgery in patients with Down syndrome. Methods. A retrospective chart review was performed of patients with Down syndrome who had undergone surgery for RRD at King Khalid Eye Specialist Hospital between 1995 and 2014. Results. A total of 245 patients with Down syndrome were evaluated during the study period. Eighteen eyes of 15 patients (6.1%) with RRD were identified. Three out of 15 patients (20%) presented with bilateral retinal detachment. All eyes presented with macula off retinal detachment. The retina was successfully reattached in 16/18 (88.8%) eyes after a mean follow-up of 48 months. The final postoperative visual acuity ranged from light perception to 20/125 (median: hand motion) (11/18 eyes). Conclusions. The anatomic success rate of retinal reattachment surgery in patients with Down syndrome is comparable to the general population. Patients with Down syndrome should undergo regular ophthalmic examinations for early diagnosis. Despite late diagnosis and the presence of proliferative vitreoretinopathy (PVR) in some patients, favorable anatomical outcomes can be achieved.

A case of recurrent, self-inflicted handheld laser retinopathy

To the Editor: We read with great interest the article by Simonett and colleagues describing a 17-year-old young man who developed a full-thickness macular hole in his right eye and bilateral macular lesions due to repeated self-inflicted handheld laser injury. The authors highlighted the importance of recognizing the clinical and multimodal imaging features of laser-induced retinopathy, because it may mimic an organic process. However, we would like to comment on two points that were raised by the authors based on a single case. First, the authors stated that the spontaneous closure of the macular hole seen in their patient has not been described before. In fact, we have previously described spontaneous closure of a laserinducedmacular hole in 1 of 17 eyes in our reported series. The patient harbored the smallest macular hole (168 mm minimum diameter) in the series. Second, Simonett and colleagues suggested delaying surgical intervention and close follow-up, anticipating spontaneous closure. We wish to emphasize that most holes in our series enlarged or remained stable in size with observation. In fact, 6 of 8 observed eyes showed enlargement of the macular hole. Based on these findings, which are unlike cases of traumatic macular holes, we caution against prolonged periods of observation (.1 month) and recommend early surgical intervention unless the macular holes are small (generally \200 mm), where a short period of observation with close follow-up may be considered.