Search

Purpose To identify systematic reviews of interventions for glaucoma conditions and to assess their reliability, thereby generating a list of potentially reliable reviews for updating glaucoma practice guidelines. Design Cross-sectional study. Participants Systematic reviews of interventions for glaucoma conditions. Methods We used a database of systematic reviews and meta-analyses in vision research and eye care maintained by the Cochrane Eyes and Vision United States Satellite. We examined all Cochrane systematic reviews of interventions for glaucoma conditions published before August 7, 2019, and all non-Cochrane systematic reviews of interventions for glaucoma conditions published between January 1, 2014, and August 7, 2019. Main Outcome Measures We assessed eligible reviews for reliability, extracted characteristics, and summarized key findings from reviews classified as reliable. Results Of the 4451 systematic reviews in eyes and vision identified, 129 met our eligibility criteria and were assessed for reliability. Of these, we classified 49 (38%) as reliable. We found open-angle glaucoma (22/49) to be the condition with the most reviews and medical management (17/49) and intraocular pressure (IOP; 43/49) to be the most common interventions and outcomes studied. Most reviews found a high degree of uncertainty in the evidence, which hinders the possibility of making strong recommendations in guidelines. These reviews found high-certainty evidence about a few topics: reducing IOP helps to prevent glaucoma and its progression, prostaglandin analogs are the most effective medical treatment for lowering IOP, laser trabeculoplasty is as effective as medical treatment as a first-line therapy in controlling IOP, the use of IOP-lowering medications in the perioperative or postoperative periods to accompany laser (e.g., trabeculoplasty) reduces the risk of postoperative IOP spikes, conventional surgery (i.e., trabeculectomy) is more effective than medications in reducing IOP, and antimetabolites and β-radiation improve IOP control after trabeculectomy. The evidence is weak regarding the effectiveness of minimally invasive glaucoma surgeries. Conclusions Most systematic reviews evaluating interventions for glaucoma are of poor reliability. Even among those that may be considered reliable, important limitations exist in the value of information because of the uncertainty of the evidence as well as small and sometimes unimportant clinical differences between interventions.

Purpose: To study clinical and histopathological findings of corneal opacification caused by thickened epithelium leading to reduced vision and topographical changes and to evaluate the outcome of its removal. Methods: Twelve patients (17 eyes) with central, paracentral or peripheral corneal opacification were reviewed to obtain their visual acuity, describe their slit lamp (SL) appearance (depth, extent and density) and document their topographic changes before and after peeling of the epithelium under SL or surgical removal under the microscope. Specimens of six cases were available for histopathological examination and immunohistochemical staining. Results: Most of the eye opacifications were secondary to corneal procedures in 10 [Penetrating keratoplasty (PKP) in 7 for congenital glaucoma, keratoconus or adherent leukoma – usually over graft-host junction –, Photorefractive keratectomy (PRK) in 2 and Phototherapeutic keratectomy in one], chronic inflammation following trachoma or non-specific causes (3), and herpetic scar (1). Three cases were considered to be idiopathic. All cases presented with decreased vision, astigmatism or changes in topography or refraction. Their vision, clinical symptoms and topography improved after treatment. Histopathologically, all six cases shared findings that are similar to what have been described as peripheral hypertrophic subepithelial corneal degeneration (PHSCD) rather than Salzmann’s nodular degeneration. None of the cases showed inflammation or subepithelial pannus formation in the excised tissue. However, our cases did not fit into the diagnosis of PHSCD because of the location of the corneal opacification (being peripheral in 41% of the corneas, the presence of underlying primary etiologic factors in 82% of the eyes and the bilateral occurrence in 5 patients. Conclusions: Meticulous SL examination aided by corneal imaging may accurately diagnose and determine the depth of corneal opacification as a cause for reduced vision. Histopathologically, the removed tissue is similar to PHSCD, but cases differ in their clinical profile. Peeling the thickened epithelial/subepithelial tissue is curative in most patients, improves visual and clinical outcome and avoids unnecessary corneal grafting. Keywords: Peripheral hypertrophic subepithelial corneal degeneration, Salzmann’s nodular degeneration, Peripheral hypertrophic subepithelial corneal opacification

Fungal keratitis accounts for 6–53% of all cases of ulcerative keratitis in variable studies. The majority of cases are due to septate fungi. The abnormal cornea in cases of dry eye syndrome, chronic ulceration, erythema multiform and possibly HIV infection is infected more commonly with Candida, most commonly Candida albicans. Candida parapsilosis affects neonates and intensive care unit (ICU) patients and it has been recently found with increasing frequency. In a previous study on mycotic keratitis in our tertiary eye hospital, filamentous fungi were more commonly isolated than yeasts. We are presenting 2 successive cases of corneal graft infection by Candida parapsilosis referred to us from another eye center to attract the attention of ophthalmologists and health workers to such an infection.

PurposeTo study the histopathological findings of the early cases of failed DSAEK grafts and to analyze the causes of graft failure.MethodsRetrospective study of 13 failed DSAEK grafts (four grafts submitted alone with no host cornea) of 12 patients. The histopathologic features are correlated with the clinical and operative findings.ResultsSignificant attenuation of the endothelial cells found in 10/13 cases (77%), retained recipient Descemet’s membrane in 7/13 (54%), variability of graft thickness in 5/13 (38%) and two of these had stromal irregularity. Retrocorneal fibrous membrane along the donor’s Descemet’s membrane was found in 4/13 (31%) resulting in endothelial detachment in one case. Eight of the nine host cornea–graft specimens were found to have: total graft-cornea detachment (in one), subtotal in four and partial (⩽50% of graft length) in three. The detached flaps showed infection at the interface of the graft–host cornea in two, epithelial ingrowth and fibrous proliferation along the anterior stromal surface of the graft (one case each). An additional histopathological finding was secondary amyloid deposition within the host stroma (in one).ConclusionIrregular or thick graft, graft–host interface fibrous/epithelial ingrowth, and infection all predispose to DSAEK failures related to graft detachment. Endothelial cells attenuation and retrocorneal fibrous membrane are major causes for primary graft failure.

Juvenile xanthogranuloma (JXG) is a benign inflammatory condition of uncertain pathogenesis. It is characterized by skin and ocular involvement – typically in the iris – in children. It has been reported in older age groups and has been also observed to involve other ocular structures such as the cornea and conjunctiva.In this case report, we are presenting an extensive right eye corneal lesion in a 43-year old male which showed the typical histopathological feature of JXG and in association with multiple endocrine neoplasia (type 1). Similar cases in the English-language literature have been also reviewed.

To review the clinical experience of fungal keratitis cases at King Khaled Eye Specialist Hospital (KKESH) in Riyadh, Saudi Arabia.Retrospective observational review and analysis of 124 patient charts with confirmed diagnosis of fungal keratitis between 1984 and 2004.One hundred and twenty four eyes of 124 patients had proven fungal infection; 101 eyes had fungal keratitis and 23 eyes had fungal endophthalmitis complicating keratitis. Estimated proportion of fungal keratitis and endophthalmitis was 10.3%. Mean age was 55 years with male predominance (79.0%). Commonly associated factors were previous intraocular surgery (38.7%) and trauma (20.9%). Major risk factor for progressing to endophthalmitis was previous intraocular surgery (65.2%), p 0.001. Initial laboratory results were fungal positive only in 30.6% (p 0.001). Commonest organisms isolated were Aspergillus spp. (29.8%) followed by Trichophyton sp. (16.1%), then Candida and Fusarium sp. Comparison of both phases of the study showed improvement in the rate of successfully treated cases from 34.6% to 58.3%, and a decline in cases progressing to endophthalmitis from 25.0% to 13.9%. Therapeutic penetrating keratoplasty increased from 26.9% to 73.6% (p 0.001). Thirteen eyes required enucleation or evisceration.In contrast to other studies on fungal keratitis, Aspergillusspp. and Trichophyton sp. were the most commonly isolated fungal pathogens; the former carries the worst prognosis. Risk factors included previous intraocular surgery and trauma. Poor outcome was associated with Aspergillus spp., delayed presentation, previous intraocular surgery and late surgical intervention. This study recommends early surgical intervention to improve the outcome.

Purpose To determine the frequency, pathology and clinical relevance of amyloid deposited in corneas of CHED. Methods Clinical and histopathological case series. Results Amyloid subepithelial deposition was found in 5 (6.6%) corneal buttons of 75 patients with histopathologically confirmed CHED diagnosis. Clinical findings included history of parental consanguinity, poor vision (ranging from counting fingers from one foot to 3/200), corneal edema, and central whitish subepithelial corneal nodules in all the five cases and positive family history in 4 of 5 cases. The patients underwent PKP at a mean age of 15years (range 3–22years). Histological findings included attenuated endothelium (6/6) thickened Descemet's membrane (6/6), stromal edema (2/6), and subepithelial amyloid deposits (6/6). All patients improved from vision point of view. To date, no recurrence of the amyloid has been seen in the grafts. Conclusion Considering the consanguinity, family history, early onset, and bilaterality, this study supports our hypothesis that the amyloid is primary in nature in our patients and indicates a new subtype of autosomal recessive CHED that require further chemical and genetic analysis. This subtype has the same prognosis for PKP as all CHED patients, if not better.

To identify clinical features and prognostic factors in patients with Fuchs' uveitis (FU). All patients diagnosed with FU at King Khaled Eye Specialist Hospital between 1983 and 2005 were reviewed. Data collected included age, gender, initial and final visual acuities, clinical findings at presentation and during follow-up visits, interval between onset of symptoms and presentation to our institute, ocular complications, details of surgical procedures, and duration of follow-up. One hundred and sixty-six patients (174 eyes) were identified. There were 92 (55.4%) males and 74 (44.6%) females with a mean age of 35.2 ± 10.5 years (range 10-70 years). The mean follow-up period was 57.3 ± 96.7 months (range 1-146 months). The most common presenting symptom was decreased vision (79.9%). Characteristic keratic precipitates (90.2%), diffuse iris stromal atrophy (100%), heterochronmia (13.9%), iris nodules (13.8%), vitreous opacity (50%) (not including sparse vitreous infiltration), cataract (85.6%) and glaucoma (27.6%) were the major clinical findings. The following factors were significantly associated with final visual acuity of 20/40 or better by univariate analysis: shorter interval between onset of symptoms and presentation (p = 0.0087), good initial visual acuity of 20/40 or better (p = 0.0356), absence of glaucoma at presentation (p = 0.0264), no glaucoma surgery (p = 0.0035), and absence of glaucoma and cataract at last visit (p = 0.0126). Logistic regression analysis revealed that final visual acuity of 20/40 or better was negatively correlated with a longer interval between onset of symptoms and presentation (odds ratio (OD) 0.201; 95% confidence interval (CI) 0.0734-0.548), and glaucoma surgical intervention (OD 0.247; 95% CI 0.0796-0.766). Initial visual acuity of 20/40 or better was positively associated with final visual acuity of 20/40 or better (OD 3.34; 95% CI 1.13-9.90). A shorter interval between onset of symptoms and presentation to our institute, better initial visual acuity, and no glaucoma surgery were significantly associated with better final visual acuity.

Purpose To report the incidence, clinical features, causative organisms, and visual outcomes associated with delayed-onset pseudophakic endophthalmitis. Methods We retrospectively reviewed the clinical records and microbiology files of all patients with culture-proven endophthalmitis that was present 6 weeks or more after cataract extraction and posterior chamber intraocular lens (IOL) implantation who were treated at King Khaled Eye Specialist Hospital (KKESH) during a 10-year period. Results From January 1997 through December 2006, 17 patients with culture-proven, delayed-onset pseudophakic endophthalmitis were treated at KKESH. Of the 17 cases, only 5 cases developed delayed-onset endophthalmitis, among 29,509 cataract surgeries performed at KKESH, indicating an incidence rate of 0.017% (5/29,509). The mean time between cataract surgery and diagnosis of endophthalmitis was 5+/-2.48 months. The culture isolates revealed Propionibacterium acnes in 7 (41.2%) eyes, polymicrobial (mixed) infections in 3 (17.6%) eyes, Staphylococcus species in 3 (17.6 %) eyes, fungal infections in 3 (17.6%) eyes, and Alcaligenes xylosoxidans in 1 (5.9%) eye. The mean follow-up period was 29.8 months. The final visual outcomes were as follows: 7 eyes (41.2%) achieved a final best-corrected visual acuity of >or=20/60; 6 eyes (35.3%) achieved a best-corrected visual acuity of or= count fingers; 2 eyes (11.8%) had hand motion to light perception vision; and 2 eyes (11.8%) were enucleated. Conclusions In this study, infection by P acnes was the most common cause of delayed-onset pseudophakic endophthalmitis and had the most favorable visual outcome, whereas fungal endophthalmitis had the worst visual prognosis.

Purpose To estimate the incidence of acute-onset endophthalmitis after cataract surgery and to report its clinical features, microbiology, and final visual outcomes. Setting King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. Methods This was a retrospective observational case series. Results The 10-year incidence of acute-onset endophthalmitis after cataract surgery was 0.068%: 0.049% for extracapsular cataract extraction (ECCE) and 0.085% for clear corneal phacoemulsification (P = .268). The incidence of endophthalmitis was 0.053% during the first 5 years of the study and 0.08% during the next 5 years. The most common presenting features were pain and poor red reflex. Of the 20 cases, 18 were culture positive. The culture isolates showed Staphylococcus species in 7 eyes (35%), Streptococcus species in 7 eyes (35%), polymicrobial or mixed infections in 3 eyes (15%), and Propionibacterium acnes in 1 eye (5%). Two patients (10%) achieved a final visual acuity of 20/40 or better, 5 (25%) had worse than 20/40 to better than 20/200, and 8 (40%) had worse than 20/200; 5 eyes (25%) were eviscerated. Visual outcomes were good in endophthalmitis cases after phacoemulsification and in cases caused by Staphylococcus epidermidis and worse in cases that had Streptococcus species endophthalmitis. Conclusions Clear corneal phacoemulsification had a 1.73-fold higher risk for acute endophthalmitis than ECCE. Although the incidence of endophthalmitis after ECCE was lower than after phacoemulsification, the outcome was much worse in post-ECCE endophthalmitis cases. Poor visual outcomes were associated with more virulent organisms and delayed presentation.

PURPOSE To compare central corneal endothelium cell density and morphology in eyes with keratoconus and unilateral resolved hydrops with the unaffected fellow eye. METHODS Bilateral confocal microscopy was performed 3 months after resolution of acute unilateral hydrops in patients with keratoconus who presented to the King Khaled Eye Specialist Hospital between February 1, 2004, and November 31, 2005. RESULTS Twenty-six patients (19 men and 7 women) with a mean age of 22 years (range, 11-36 years) were enrolled in the study. A history of ocular allergy or rigid gas-permeable hard contact lens wear was present in 14 and 12 patients, respectively. The mean interval to resolution of hydrops was 12 weeks (range, 9-14 weeks), after which neovascularization was present in 8 eyes. The mean endothelial cell density in affected and unaffected eyes was virtually identical (2759 vs. 2788 cells/mm2, respectively; P = 0.82), although 5 (19.2%) affected eyes did have endothelial cell density that was >15% less than that of the unaffected fellow eye. Compared with unaffected eyes, there was a mean increase polymegathism in affected eyes from 33% to 35% and a mean decrease in hexagonality from 60% to 55%, but these differences were not statistically significant (P = 0.11 and 0.06, respectively). CONCLUSIONS Decreased endothelial cell density is uncommon after resolution of acute hydrops, although morphologic changes may be present in a majority of cases.

Purpose: The aim was to determine the frequency and describe the main histopathologic features of corneal stromal dystrophy in Saudi Arabia. Methods: A single-center, retrospective analysis of 193 corneal specimens diagnosed with stromal dystrophy. All samples were retrieved from the Histopathology Department at King Khaled Eye Specialist Hospital over a 10-year period (2002 to December 31, 2011). Cases of stromal dystrophy undergoing keratoplasty were included in the study. Routine histopathologic stains and specific stains were used to determine a diagnosis. The corresponding demographic data and basic clinical/surgical information were collected via chart review. Results: The study sample was comprised of 193 eyes. The final diagnoses were macular corneal dystrophy (MCD) in 180 (93.26%) eyes, granular corneal dystrophy (GCD) in 9 (4.66%) and lattice corneal dystrophy (LCD) in 4 (2.07%) eyes. The mean age at presentation was 27.03 years for MCD, 26.33 years for GCD and 53.75 years for LCD. The interval between diagnosis and surgical intervention was not statistically different between the macular and granular groups (P = 0.141). There was a positive family history for the MCD (37.22%) and GCD (44.44%) groups. All eyes underwent penetrating keratoplasty (PKP) except 10 MCD cases that underwent lamellar keratoplasty. Diffuse stromal deposits were present in 87.2% of MCD corneas and 66.67% of GCD corneas. Seventeen eyes with MCD were misdiagnosed as GCD. None of the LCD cases were clinically identified since all of these cases were diagnosed as corneal scarring. In eyes with MCD that underwent PKP, there was diffuse stromal involvement (in 87.22% eyes) and changes in Descemet's membrane (in 53.5% eyes). Conclusion: This pathological study suggested that MCD was the most common corneal stromal dystrophy that required keratoplasty in Saudi Arabia. Patient with MCD and GCD presented at a significantly younger age than LCD. The clinical diagnosis of MCD is not achieved in all cases likely due to a more severe phenotype in the Saudi population or the presence of corneal scarring that is associated with previous trachoma, which obscures the classical appearance of LCD. We believe that PKP is first-line surgical treatment, especially for MCD because it involves all corneal layers. However, deep stromal involvement and changes in Descemet's membrane in MCD should be considered when selecting the surgical procedure.

To study the association between congenital aniridia and dry eyes, and the status of limbal stem cells.Single-center, retrospective, noninterventional, comparative case series.Twenty patients (36 eyes) diagnosed with congenital aniridia.Retrospective review of medical records at the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia to identify all cases of congenital aniridia. Selected patients were requested to undergo further testing, especially for evaluation of dry eyes. Full ocular examinations were performed, including examination of the meibomian gland orifices and dry eye evaluation (by predetermined criteria of tear breakup time, tear meniscus level, presence of mucoid secretions, Schirmer's test with and without anesthesia, and fluorescein and rose Bengal staining patterns of the cornea and conjunctiva). Cytological evaluation was performed in 23 aniridic eyes by impression cytology to determine limbal stem cell status relative to control normal eyes.Abnormal tear film production and stability, meibomian gland dysfunction, severity of corneal involvement, and limbal stem cell deficiency.Twenty patients (36 eyes) diagnosed with congenital aniridia were classified into 3 groups according to the severity of corneal involvement: mild (2 eyes), moderate (21 eyes), and advanced (13 eyes) corneal changes. Tear breakup time was reduced by an average of 5 seconds in 90.7% of cases, tear meniscus levels were reduced to0.5 mm in 88.6% of cases, and stenosed meibomian orifices were found in 77.8% of patients. Dry eyes (94%) correlated with the severity of corneal involvement (P = 0.001). Impression cytology revealed metaplasia in all tested cases. Furthermore, 8 of 23 eyes (35%) and 15 of 23 eyes (65%) had early and advanced limbal stem cell deficiency, respectively.Abnormal tear film stability and meibomian gland dysfunction are newly identified factors in patients with aniridia. Both correlate to the severity of ocular surface disease. Impression cytology is informative in diagnosing various degrees of limbal stem cell deficiency, which is present in all tested aniridia eyes.

Purpose: Listeria monocytogenes is an aerobic, motile, gram positive bacillus recognized as an intercellular pathogen in human where it most frequently affects neonates, pregnant women, elderly patients, and immunosuppressed individuals as well as healthy persons. Ocular listeriosis is rare, most frequently in the form of conjunctivitis, but has been also shown to cause rarely endophthalmitis with pigmented hypopyon and elevated intraocular pressure such as in our case. Materials and Methods: We are reporting one immunocompetent patient presenting with dark hypopyon following laser refractive procedure. His clinical findings, investigations, and further management are all described with relevant literature review of similar cases. Results: Diagnosis of ocular listeriosis was confirmed by positive culture of anterior chamber (AC) aspirate with identification of the above organism. His visual outcome was satisfactory with good preserved vision. Conclusion: We believe that his ocular infection was exogenous and that ophthalmologists should be aware of the causative organisms of colored hypopyon to avoid delayed diagnosis.

Objective To describe three cases of squamous cell carcinoma of the conjunctiva presenting with corneal and scleral inflammation, thinning, and perforation without any tumor formation. Design Three case reports. Participants Three male subjects aged 76, 66, and 61 years. Intervention The subjects had symptoms of external ocular inflammation with focal corneal or scleral thinning and inflammation, as well as interstitial keratitis in two cases. Initial diagnosis of sclerokeratitis with limbal thinning was made in all three in addition to a pterygium in case 2. Main outcome measures Diagnosis of the carcinoma was delayed for 2 to 24 months in two cases, whereas case 2 was diagnosed on excision of a pterygium from the involved area. Results All subjects developed intraocular extension after further scleral thinning and perforation without tumefaction. Conclusions Squamous cell carcinoma of the conjunctiva may be seen without a distinct mass and can masquerade as sclerokeratitis, scleromalacia, or interstitial keratitis. It seems that diffuse growth with inflammation leads to thinning, necrosis, and perforation of the ocular wall with resultant intraocular spread. Squamous cell carcinoma should be considered in the differential diagnosis of corneal and scleral thinning, perforation, and inflammation of unknown cause, especially in the older male subject.

Purpose To analyse the distribution and types of collagen in the conjunctiva of patients with trachoma and vernal keratoconjunctivitis (VKC). Methods Conjunctival biopsy specimens were collected from 9 patients with active trachoma, 9 patients with scarred trachoma, 6 patients with active VKC and 9 control subjects. The presence and distribution of collagen was assessed microscopically with immunohistochemical techniques and a panel of monoclonal and polyclonal antibodies directed against types I, III, IV and V collagen. Results In normal conjunctiva, the staining for types I and III collagen was localised to the substantia propria. Type IV collagen was located in the epithelial, vascular endothelial and accessory lacrimal gland basement membranes. Staining for type V collagen was absent. New type V collagen deposition close to basement membranes was noted in active trachoma, scarred trachoma and VKC. The extent of deposition of type V collagen was markedly increased in scarred trachoma when compared with active trachoma. Staining for type IV collagen showed irregularly thickened epithelial basement membrane in active trachoma, and a marked increase in basement membrane type IV collagen was noted in scarred trachoma. Immunoreactivity of types I and III collagen increased in active trachoma and decreased in scarred trachoma. VKC conjunctiva contained increased amounts of types I, III and IV collagen due to marked increase in the thickness of vascular endothelial basement membrane and very prominent deposition of types I and III collagen around stromal vessels. Conclusions Our data indicate new type V collagen formation in the conjunctiva from patients with active trachoma, scarred trachoma and VKC. Increased deposition of types I, III and IV collagen is noted in VKC and active trachoma. Our findings suggest that increased deposition of type IV collagen and new type V collagen formation contributes to the development of conjunctival fibrosis in scarred trachoma.

Purpose To determine the prevalence, microbiological profile, and prognosis for bacterial keratitis after primary pediatric penetrating keratoplasty (PKP). Design Retrospective case series. Methods Retrospective review of all cases of primary PKP performed in children 12 years of age or younger at the King Khaled Eye Specialist Hospital between January 1, 1990 and December 31, 2005 and inclusion of all postoperative cases of culture-positive, bacterial keratitis. Results Culture-positive bacterial keratitis developed in 35 (17.3%) of 202 primary keratoplasties. Gram-positive organisms were cultured in 91.4% of infected eyes and accounted for 77.6% of isolates. Streptococcus pneumoniae was the most common organism. No eyes achieved a final visual acuity of 20/40 or better, while 65.7% had hand motions or worse. Conclusions Bacterial keratitis after pediatric keratoplasty is a serious complication that is associated with a high risk of graft failure and poor visual outcome.

PURPOSE: To report a 10-year follow-up for bilateral implantation of a Chiron Adatomed silicone posterior chamber phakic intraocular lens (PIOL). METHODS: A 32-year-old man presented with bilateral blurred vision and monocular diplopia in the left eye of 2 years' duration. RESULTS: Slit-lamp microscopy showed bilateral anterior subcapsular cataract and temporal PIOL decentration, and no visible space between the PIOL and crystalline lens in the right eye. After explantation of the posterior chamber PIOL, lens aspiration, and IOL implantation, uncorrected visual acuity improved to 20/15 in the right eye. Scanning electron microscopy examination showed denser deposits on the central portion of the back surface when compared with the edges. CONCLUSIONS: Long-term follow up of certain designs of posterior chamber PIOLs may reveal late occurrence of complications. Cataract formation may be related to direct contact between the implanted and crystalline lenses. [J Refract Surg. 2006;22:513-515.]

To determine the immunophenotype or immunophenotypes of macular corneal dystrophy in Saudi Arabia.We studied 56 cases of macular corneal dystrophy. Tissue from 60 corneal transplant buttons was stained by the avidin-biotin complex method using an anti-keratan sulfate monoclonal antibody. The serum antigenic keratan sulfate was measured in 23 of the 56 patients, four unaffected relatives, and 13 individuals with chronic actinic keratopathy. Serum and corneal tissue were studied in 17 of the 50 affected individuals with corneal transplant material.Thirty-five corneas (58.3%) of 29 of 50 patients did not react with anti-keratan sulfate monoclonal antibody. The stroma and abnormal intracellular and extracellular corneal accumulations reacted with anti-keratan sulfate monoclonal antibody in seven corneas (11.7%). The stroma in the other 18 corneas (30.0%) from 15 patients did not react with the anti-keratan sulfate monoclonal antibody, but corneal fibroblasts did. Twenty-one of the 23 patients with macular corneal dystrophy had no detectable serum antigenic keratan sulfate (9 ng/ml); two had values of 12 and 51 ng/ml, respectively, and their corneal stroma and abnormal accumulations reacted with anti-keratan sulfate monoclonal antibody.We detected macular corneal dystrophy type IA, a new immunophenotype characterized by the lack of detectable antigenic keratan sulfate in the serum (9 ng/ml), and a corneal stroma that did not react with the keratan sulfate monoclonal antibody but in which corneal fibroblasts did react with keratan sulfate monoclonal antibody (in 15 of 50 patients).

The purpose of the study is to determine the outcome of penetrating keratoplasty in congenital hereditary endothelial dystrophy.Records of 40 patients (13 males, 27 females) who underwent penetrating keratoplasty (56 eyes) were reviewed. The mean age at surgery was 11.8 years (range, 2 months-35 years). The mean follow-up was 37 months (range, 6-136 months).In 35 (62.5%) of 56 eyes that underwent primary penetrating keratoplasty, the grafts survived. Graft survival analysis showed the probability of obtaining a clear graft is 92% at 1 year, 72% at 2 years, and 56.5% at 5 years. Graft survival was statistically better in eyes where onset of the disease is delayed (P = 0.02), if the graft donor age is between 5 and 30 years versus older than 30 years (P = 0.02), and for patients who kept follow-up appointments versus those who were delinquent (P0.03). Visual acuity was 20/40 in 1.9%, 20/50 to 20/80 in 18.9%, 20/100 to 20/300 in 49%, and less than 20/400 in 30.2%. The main causes of graft failure were graft rejection (six eyes) and bacterial keratitis (four eyes).Penetrating keratoplasty in congenital hereditary endothelial dystrophy is moderately successful, and graft survival is better in cases of delayed onset compared with that of congenital onset. Early surgical intervention is recommended to prevent development or progression of amblyopia.

Objective: To study the outcome ofphacoemulsification (PE) compared to standardextracapsular surgery before the introduction ofstate-of-the-art techniques (capsulorhexis,hydrodissection, nuclear cracking, nuclear chopping,sutureless incisions) and sophisticated equipment. Study design: Charts from 375 patients (453 eyes)undergoing PE between 1984 and 1989 were randomlyselected and studied retrospectively. A minimum ageof 35 years, and a minimum follow-up of three monthswere required.Setting: A large eye hospital in the Kingdom of SaudiArabia staffed with an international faculty ofophthalmic surgeons.Patients: Patients over 35 years of age undergoing PE for immature, mature and traumatic cataract.Main outcome measures: Postoperative visual acuity,and rate or frequency of intraoperativecomplications. Results:66.5% achieved visual acuity of 20/40 orbetter, which compares favourably with the 36.5% ofeyes reaching this level of visual acuity after mainlystandard extracapsular cataract surgery in anotherstudy at our hospital. Posterior capsule rupturesoccurred in 7.5% and vitreous loss in 5.5%. Otherocular disease (odds ratio 7.51 confidence interval4.43-12.7) and intraoperative complications (oddsratio 2.97 confidence interval 1.38-6.42) werestatistically significant predictors for final visualacuity of under 20/40 (p =

Over a quarter of century ago, 27 years actually, the first issue of the Saudi Journal of Ophthalmology was published. The SJO has a long and rich history in serving the ophthalmic community in the Kingdom, Gulf States and the Middle East. The SJO is published by one of the first medical societies formed in the Kingdom of Saudi Arabia and is the official journal of the Saudi Ophthalmological Society with support from King Saud University. The first issue of SJO was published in January 1986 as the Saudi Bulletin of Ophthalmology. In 1991 the name was changed to the Saudi Journal of Ophthalmology to reflect the true spirit and mission of the Society and the Journal. Since inception, the journal’s mission has been to provide high quality clinical and scientific manuscripts relevant to eye diseases in the region. However the advent of the Internet meant that most scientists and clinicians eventually adopted online searches for relevant information and knowledge. Additionally many authors will only submit to Journals that are indexed in online scientific databases in order to increase the visibility of their research. In keeping with this reality, the SJO proactively addressed this issue and it is my pleasure to announce that the Saudi Journal of Ophthalmology (SJO) is now indexed in PubMed Central. PubMed Central is the most used biomedical bibliographic database and is an authoritative source of knowledge for clinicians and scientists worldwide. This milestone could not have been achieved without the past and current support of the King Saud University, our Editorial and Advisory Boards, the Reviewers and Authors. With its support, King Saud University has provided the Journal, a platform to reach a global audience. King Saud University assisted in the provision of services from Elsevier, one of the leading publishers of scientific journals. This enabled all submissions to be processed online with technical support available to Authors, Reviewers and the Editors. The outcome include faster manuscript processing, reduced costs, instant reports, transparency of the publication process and timely publication of manuscript. From 2009 onwards, the journal has been available online (www.saudiophthaljournal.com), via ScienceDirect and other online archives. The SJO is an open access journal and all the articles are available free of charge to readers. The journal maintains a standard of timely reviews and serves as a resource for the educational needs of Ophthalmologists and Allied Health Care Personnel by focusing on clinically relevant manuscripts. The Journal also publishes thematic issues on a regular basis. For example, in the last two years SJO has published special issues on oculoplastics, diabetic retinopathy, cornea and refractive surgery, glaucoma, cataract, ophthalmic pathology, pediatric ophthalmology and oculoplastics imaging. Many internationally renowned ophthalmologists shared their experience and expertise by contributing original/review articles for these issues. Thematic issues are very popular as they serve as convenient reference/guide of cogent current information on a particular topic in Ophthalmology. Due to feedback for the readership, the Journal will continue to publish regular thematic issues. We are fortunate to have outstanding, proactive editorial and international advisory boards comprised of well-regarded experts from all over the world. Currently, the editorial and international advisory boards comprise of 32 clinicians, professors and researchers from 13 countries. The diversity of experience and knowledge allows unique and varied perspectives that enhance the quality of the SJO. Based on this experience and looking to the future we are currently expanding these boards to meet our ongoing endeavors. I take this opportunity to express my gratitude at the diligence and outstanding work of the Board members who have actively participated and lead the arduous task of managing some of the thematic issues. The success of the peer-reviewed journal depends on the willingness of our colleagues to set aside time from their practices, academic requirements and in some cases, family to critique articles. The editorial board would like to thank all the Referees for the rigor of their work and those who continue to support the Journal in the future. To the authors, many thanks for your submissions and for the trust you have placed in the SJO. Your reward is the increased visibility of your research now that SJO is indexed in the foremost database of biomedical and scientific literature worldwide. The board would also like to thank Elsevier for providing the excellent publishing services and helping the journal in achieving its goals. Obtaining indexing in PubMed is indeed rewarding and quite an accomplishment. All articles published in this issue are available in PubMed Central. Subsequently, all back issues will be made available in a timely fashion. The next goal for the Editorial Board to have the SJO indexed with the Institute for Scientific Information (ISI) Web of Knowledge and have it listed on MedLIne. In order to achieve these goals, we need your active participation as an author, as a referee and as a reader of the journal.

BACKGROUND: Twenty-three eyes of 22 patients remained undercorrected 5 to 49 months after radial keratotomy, either alone or in combination with transverse keratotomy. METHOD: We attempted to correct the residual myopia ranging from -1.25 to -5.75 diopters (D) (with astigmatism of 0 to 1.25 D) with photorefractive keratectomy. The mean age of patients was 26 years (range 22 to 40 years). RESULTS: After photorefractive keratectomy (follow-up 6 to 17 months) uncorrected visual acuity was equal to or better than 20/20 in 39% (9 eyes), better than 20/25 in 65% (15 eyes), and better than 20/40 in 74% (17 eyes). Spectacle-corrected visual acuity was equal or better than 20/40 in all eyes; one eye (4%) lost two lines of spectacle-corrected visual acuity. Refractive error was within ±0.50 D in 48% (11 eyes) and within ±1.00 D in 65% (15 eyes). Undercorrections of more than 1.00 D occurred in 22% (5 eyes) and overcorrections of more than 1.00 D occurred in 13% (3 eyes). No or minimal haze was present in 57% (13 eyes), mild haze in 39% (9 eyes) and moderate haze in 4% (1 eye). Final uncorrected visual acuity was better (p=0.0002) and haze was less (p=0.003) in the group with less than -3.00 D than in the group with greater than or equal to -3.00 D. CONCLUSION: Photorefractive keratectomy after radial keratotomy is safe but less effective and less predictable in eyes with greater than or equal to -3.00 D compared to those with less than -3.00 D. [J Refract Surg 1996;12:801-805]

BACKGROUND: Epikeratoplasty for keratoglobus performed to tectonically support the thin globular cornea may have complications such as interface opacities. METHODS: We report the case of a patient with persistent interface opacities and epithelial cysts following epikeratoplasty for keratoglobus that were treated primarily by washouts and repeated argon laser photocoagulation. RESULTS: Interface opacities led to massive epithelial inclusion cysts. Direct removal of these cysts and placement of a new lamellar graft resulted in a favorable outcome. CONCLUSION: Massive epithelial inclusion cysts may develop in the lamellar interface after epikeratoplasty. Direct surgical removal was successful. [J Refract Surg. 1996;12:517-520.]

BACKGROUND: Phototherapeutic keratectomy (PTK) is an effective treatment for many superficial corneal disorders. The efficacy of PTK for the treatment of climatic droplet keratopathy (CDK) has not been reported. METHODS: We report the results of excimer laser (Summit Technology, Inc, Waltham, Mass) PTK on 75 eyes (67 patients) with "smooth" climatic droplet keratopathy (55 eyes) and "irregular" climatic droplet keratopathy (20 eyes) in whom more than 6 months of follow up are available. RESULTS: PTK was successful in reducing corneal opacification in both smooth (98%) climatic droplet keratopathy and irregular (80%) climatic droplet keratopathy. Achievement of a clear or mildly hazy cornea following PTK was more likely to occur with smooth (80%) climatic droplet keratopathy than irregular (25%) climatic droplet keratopathy (P=0.01). Eyes with smooth climatic droplet keratopathy were more likely to obtain more than one line of improved uncorrected (56% vs. 25%) or spectacle-corrected visual acuity (61.8% vs. 21.2%) than those with irregular climatic droplet keratopathy (P=0.03 and 0.005, respectively). Delayed re-epithelialization (longer than 14 days) was more common in irregular CDK (21%) than in smooth CDK (9%), as was the incidence of secondary microbial keratitis (10.0% vs. 1.8%). CONCLUSIONS: PTK is effective in reducing superficial corneal opacification in CDK, although serious complications may occur, especially in advanced irregular CDK. [J Refract Surg. 1996;12:114-122.]

BACKGROUND: Phototherapeutic keratectomy (PTK) is effective in the treatment of many superficial corneal disorders. The incidence of bacterial keratitis following PTK has not been assessed in a large, prospective clinical trial. METHODS: We report three cases of bacterial keratitis that occurred in a prospective study of 258 consecutive PTK procedures at King Khaled Eye Specialist Hospital. RESULTS: Three (1.2%) of 258 eyes developed bacterial keratitis during a period of follow up ranging from 1 to 24 months. All three cases were in 183 eyes (1.6%) with a diagnosis of climatic droplet keratopathy, while no cases were observed in 75 eyes with other anterior corneal disorders. Gram-positive species (Streptococcus pneumonia in two, coagulase-negative Staphylococcus in one) were the predominant species isolated from all three cases. Two of the cases were polybacterial. The final visual outcomes ranged from 20/125 to 20/400. CONCLUSIONS: The risk of bacterial keratitis following treatment of superficial corneal disorders with PTK is low but its occurrence may adversely affect the final visual outcome. [J Refract Surg. 1996;12:123-127.]

To report the long-term follow-up and visual outcome after excision of a traumatic iris cyst. A 4-year-old female presented with an iris cyst in her left eye 2 years after corneal laceration repair. An 8 × 7 mm cyst was located between 1 and 6 O’clock on the iris, extending into the anterior chamber. The cyst was surgically removed by dissection from the endothelium and angle by viscoelastic and was submitted for histopathological examination. Postoperative outcomes including visual acuity (VA) and complications over 8 years are reported. Histopathological examination demonstrated fragments of iris tissue extensively covered by a layer of epithelial cells which were present on both the anterior and posterior surfaces of portions of the iris stroma. 8 years post-excision, the patient’s VA improved from 20/80 to 20/30 with no evidence of recurrence and no adverse sequelae. Traumatic iris cyst is a diagnostic and therapeutic challenge for ophthalmic surgeons with an overall poor visual prognosis if it is not excised properly. Improved wound management techniques during the repair of a traumatic wound are highly recommended. Careful viscoelastic dissection of the iris cyst from the endothelium and angle provided acceptable long-term outcome and prevented recurrence.

A population-based survey of the prevalence of major causes of blindness and visual impairment was conducted in Bisha region, Saudi Arabia. Overall, 2882 people were examined. The prevalence of blindness (visual acuity of < 3/60 in the better eye with best available correction) was 0.7% and the prevalence of visual impairment (visual acuity < 6/12 but ≥ 3/60 in the better eye with best available correction) was 10.9%. Cataracts were responsible for 52.6% of blindness and 20.6% of visual impairment. Refractive errors accounted for 67.9% of visual impairment. Proper management of cataracts and correction of refractive errors will cure 73.6% of blind subjects and 88.5% of visually handicap people in this part of the world.

Purpose To report on a case of episcleral hemangioma in a child. Methods A 3-year-old boy presented with a 4-week history of limbal mass in the left eye and had an excision of that mass. Results There was an 8 × 7 mm oval lesion, 3–4 mm below the inferior limbus. It was reddish, sharply elevated with smooth surface, and firmly attached to the underlying sclera with two large blood vessels over it. Histopathologic examination demonstrated a cellular lesion containing vascular spaces of various sizes. The solid appearance indicated an increase of cells that appear to be consistent with endothelial cells which formed a nest surrounded by PASpositive strands. Small to moderate size capillaries were evident throughout the solid portion of the lesion. These findings were consistent with episcleral hemangioma of capillary type. Conclusions Episcleral hemangioma is a rare tumor and should be included in the differential diagnosis of episcleral tumors. To our knowledge, this is the first reported case of episcleral hemangioma in a child as an isolated finding.

Climatic droplet keratopathy (CDK) is a degenerative disease of the cornea, highly prevalent in Saudi Arabia. It is characterized by aggregates of small, golden-yellow globules that accumulate in the subepithelial layers, Bowman's layer, and the superficial stroma of the cornea. The authors report on 22 patients (40 eyes) with CDK and lattice lines in the cornea. The condition occurred late in life (mean age, 67 years). It was bilateral in 82% of patients, with no family history of lattice dystrophy or systemic amyloidosis. These lines were found in all layers of the stroma. Results of histopathologic and electron microscopic examination of the lattice lines confirmed the presence of amyloid. Results of immunohistochemical examination showed evidence of deposition of AP protein. The cause of these deposits in the cornea is not known, but the authors speculate that environmental factors causing CDK also may play a role in the deposition of protein AP in the cornea. The contribution of trachoma to the degenerative changes in the cornea and secondary amyloidosis could not be ruled out, as all patients had inactive trachoma. Climatic droplet keratopathy with corneal amyloidosis, therefore, represents a form of "lattice degeneration" of the cornea.

Purpose To report 6 eyes of 5 patients with transient corneal edema after exposure to the milky latex of Calotropis procera (ushaar). Methods Interventional case series. Results Intracorneal penetration of ushaar latex can lead to permanent endothelial cell loss with morphologic alteration. Corneal edema resolved completely in approximately 2 weeks in all cases, despite reduced endothelial cell count and abnormal morphology. Conclusions Corneal endothelial toxicity of ushaar latex is caused by its ability to penetrate the corneal stroma and induce permanent loss of endothelial cells. Corneal edema resolves if sufficient endothelial cell viability is still present after resolution of ushaar keratitis.

Acute hydrops occurs in approximately 3% of eyes with keratoconus.1 The incidence increases dramatically in eyes with associated vernal keratoconjunctivitis.2,3 Neovascularisation rarely develops after resolution of acute hydrops although it has been reported with large area of involvement with hydrops associated with either close proximity to the limbal vascular arcades4 or intrastromal clefts.5 The association between patient age and area of involvement of hydrops, with the subsequent risk of development of neovascularisation, has not been adequately addressed in a prospective clinical trial. In Saudi Arabia, patients present with severe keratoconus at a much younger age than in Western populations and have a higher incidence of associated atopic eye disease.2,3 The average age at the time of penetrating keratoplasty in our patient population is 19 years, with …

Purpose To compare the visual outcomes and complications of laser in situ keratomileusis (LASIK) with those of surface treatment by laser-assisted subepithelial keratectomy (LASEK), photorefractive keratectomy with mechanical epithelial removal (M-PRK), and transepithelial photorefractive keratectomy (T-PRK). Setting Tertiary care eye center. Methods This retrospective review comprised all cases of LASIK, LASEK, M-PRK, and T-PRK performed at King Khaled Eye Specialist Hospital between July 1, 2004, and June 30, 2005. Separate statistical analyses were performed for eyes with low to moderate myopia (spherical equivalent [SE] less than −6.00 diopters [D]) and high myopia (SE −6.00 to −11.25 D). Results Of 696 eyes that met the inclusion criteria, 464 had LASIK, 104 had LASEK, 69 had M-PRK, and 59 had T-PRK. Eyes with low to moderate myopia had a statistically significantly smaller mean difference between logMAR final postoperative uncorrected visual acuity (UCVA) and preoperative best spectacle-corrected visual acuity (BSCVA) after T-PRK and M-PRK than after LASIK or LASEK. A higher percentage of eyes with high myopia had a final UCVA within ±2 lines of the preoperative BSCVA with T-PRK than with LASIK, LASEK, or M-PRK. There were more major non-flap–related complications after LASEK than after LASIK, M-PRK, or T-PRK. Conclusions In eyes with low to moderate myopia, T-PRK and M-PRK provided slightly better visual outcomes than LASIK or LASEK. In eyes with high myopia, T-PRK provided better visual outcomes than LASIK, LASEK, and M-PRK. Laser in situ keratomileusis was associated with the most major postoperative complications.

Objective This study aimed to determine whether heparin surface-modified (HSM) intraocular lenses (IOLs) with a hydrophilic surface would reduce cell adherence and other postoperative changes compared with the conventional polymethylmethacrylate (PMMA) IOLs in patients with either diabetes mellitus or inactive uveitis. Design The study design was a randomized, double-masked, clinical trial. Participants Twenty-five patients with bilateral cataracts, 14 with inactive anterior uveitis and 11 with diabetes, with an age range of 11 to 81 years (mean, 52.8 years) participated. Intervention Bilateral cataract extraction with posterior chamber IOL implantation was measured, each patient receiving an HSM lens in one eye and a PMMA lens in the other. Pharmacia one-piece HSM and PMMA IOLs were used. Postoperative ocular changes were evaluated at regular intervals for 24 months in patients with inactive uveitis and for 6 months in patients with diabetes. Patients and physicians alike were unaware of which eye contained which lens until postoperative results were compiled. Records were kept by a study coordinator. Main outcome measures Comparisons of posterior synechiae, IOL cellular deposits, and posterior capsular fibrosis between PMMA and HSM IOLs were measured. Results Using the chi-square test, no statistically significant difference was found between the HSM and PMMA IOLs in the number of cellular deposits found on the anterior IOL surface, the number of adhesions between the iris and IOL, or the incidence of capsular opacification. Conclusion The HSM and PMMA IOLs showed similar postoperative results in patients with inactive uveitis or diabetes mellitus.

Penetrating keratoplasty in children has been documented to have a higher rate of graft failure and a worse visual prognosis than adult keratoplasty.We undertook a retrospective review of all cases of primary penetrating keratoplasty performed in children 12 years of age or younger at the King Khaled Eye Specialist Hospital between January 1, 1990, and December 31, 2003.One hundred sixty-five primary penetrating keratoplasties were performed in 134 children during the study interval. The surgical indications were congenital opacities in 130 eyes (78.8%), acquired, traumatic opacities in 18 eyes (10.9%), and acquired, nontraumatic opacities in 17 eyes (10.3%). Among congenital opacities, 35 cases were caused by congenital hereditary endothelial dystrophy (CHED). The median follow-up for 73 grafts (44.2%) that remained clear was 50 months (range, 12-50 months), whereas the median follow-up for 92 grafts (55.8%) that failed was 6 months (range, 1-54 months). Kaplan-Meier graft survival was significantly higher at all postoperative intervals in eyes with CHED than for other surgical indications (p0.001). Eyes with CHED were significantly more likely to achieve ambulatory vision or vision20/200 than eyes with other indications (p0.001).Pediatric keratoplasty was associated with an excellent prognosis for graft survival in eyes with CHED and a fair prognosis for graft survival in eyes with non-CHED congenital opacities and acquired opacities. The best visual prognosis was obtained in eyes with CHED and the worst prognosis was for non-CHED congenital opacities.

To identify changing indications for keratoplasty over the last 20 years at a tertiary care eye hospital in a country with rapidly evolving ophthalmic care services.A retrospective review was performed of the eye bank records of every patient who received a lamellar or penetrating keratoplasty at the King Khaled Eye Specialist Hospital in Riyadh, Saudi Arabia, between January 1, 1983 and December 31, 2002. For each case, the primary surgical indication was identified.A total of 8318 corneal transplants were performed during this 20-year period. In the first 5 years of the study, the leading indications for corneal transplantation were corneal scarring (52.0%), aphakic/pseudophakic bullous keratopathy (13.5%), corneal degeneration (10.0%), and keratoconus (7.6%). During the last 5 years of the study, the leading indications for corneal transplantation were keratoconus (40.2%), corneal scarring (19.8%), failed corneal transplant (11.3%), and corneal ulceration (10.2%). There was a dramatic increase in the number of transplants performed for keratoconus (441%) and failed corneal transplants (285%) as well as a dramatic decrease in the number of transplants performed for corneal degeneration (-88%) and scarring (-60%) between the first and last 5 years of the study period.Major changes in the indications for corneal transplantation were related to the introduction and expansion of modern ophthalmic services at a time of rapid socioeconomic development and population growth.

PURPOSE: To report a case of permanent endothelial cell injury after intracorneal penetration of milky latex from Calotropis procera (ushaar). DESIGN: Interventional case report. METHODS: A 40-year-old patient developed painless corneal edema despite minimal epithelial injury after exposure to ushaar latex. RESULTS: Confocal and specular microscopy confirmed permanent endothelial cell loss with morphologic alteration after intracorneal penetration of ushaar latex. Corneal edema resolved completely after 2 weeks, although reduced endothelial cell count and abnormal morphology persisted. CONCLUSION: Ushaar latex is capable of penetrating the corneal stroma and inducing permanent loss of endothelial cells. Corneal edema resolves if sufficient endothelial cell viability is still present after resolution of ushaar keratitis.

To determine the prognosis of penetrating keratoplasty (PK) for macular corneal dystrophy (MCD).Single-center, retrospective, interventional, noncomparative case series.One hundred forty-one patients (229 eyes) with MCD.Retrospective review of the medical record of every patient who underwent primary PK for histopathologically confirmed MCD at the King Khaled Eye Specialist Hospital between January 1, 1983 and December 31, 2002 and for whom at least 12 months of follow-up is available.Visual acuity (VA), graft survival, and postoperative complications.After a mean follow-up period of 5.9+/-3.8 years (range, 1-17), the mean best-corrected VA was 20/50. At the most recent visit, 206 (90.0%) grafts were clear, and 23 (10.0%) had failed. Probabilities of graft survival were 98.1% at 1 year, 89.8% at 5 years, 82.1% at 10 years, and 74.1% at 15 years. There was a statistically significant increased likelihood of graft failure if the patient was older than 40 years at the time of surgery (P0.00003). The differences in graft failure between patients older than 40 and those younger were not attributable to statistically significant differences in duration of follow-up, donor age, or donor endothelial cell counts. Corneal endothelial rejection episodes occurred in 47 (20.0%) grafts, but resulted in irreversible graft failure in only 8 (3.5%) eyes. Eighteen (27.3%) of 66 eyes with a recipient size ofor =7.5 mm developed a graft rejection episode, compared with 27 (16.6%) of 163 eyes with a recipient size of7.5 mm (P = 0.04). Microbial keratitis occurred in 14 (6.1%) grafts and was more likely to occur in patients over 40 (14.0% vs. 3.0%, P = 0.01). Clinically significant recurrence was observed in 12 (5.2%) grafts, after a mean interval of 84+/-48.2 months, and was directly related to patient age (P = 0.04) and inversely related to donor graft size (P = 0.04).Good visual results and excellent graft survival can be achieved after PK for MCD. The risk of graft failure is higher in patients older than 40 years.

Objective To report ocular complications of Rift Valley fever (RVF) during its first reported outbreak in southwest Saudi Arabia in autumn 2000. Design Cross-sectional study of patients in a referral hospital. Participants One hundred forty-three consecutive patients with confirmed RVF serologic test results and ocular lesions were enrolled in the study. Methods Hospitalized patients (n = 30) and outpatients (n = 113) with clinical symptoms consistent with RVF, positive RVF serologic test results, and ocular abnormalities were studied. Ophthalmologic examinations, including fundus photography and fluorescein angiography, were performed. Patients were followed up at regular intervals to determine the prognosis and outcome of identified ocular abnormalities. Main outcome measures Visual acuity at initial presentation and course of anterior and posterior segment complications. Results Among 143 patients (78% males; mean age, 53.2 years), 212 eyes were affected, comprising 47 eyes in 30 inpatients and 165 eyes in 113 outpatients. The mean interval between the onset of RVF and visual symptoms ranged from 4 to 15 days (mean, 8.8 days). Macular or paramacular retinitis was identified in all the affected eyes (n = 212) at the time of initial assessment. Lesions included retinal hemorrhages (40%), vitreous reactions (26%), optic disc edema (15%), and retinal vasculitis (7%). Anterior uveitis was present in 31% of outpatients. Fluorescein angiography of the retinitis showed early hypofluorescence with late staining of retinal lesions and blood vessels. Initial visual acuity was less than 20/200 in 80% of eyes in the outpatient group; their vision improved, deteriorated, or remained the same in 13%, 15%, or 72%, respectively. Evaluation at the last follow-up showed macular (60%) or paramacular (9%) scarring, vascular occlusion (23%), and optic atrophy (20%) in the outpatient group. Conclusions Rift Valley fever was associated with major ocular morbidity. Ocular manifestations of RVF occurred with a relatively higher frequency than reported up to now and were not limited to severe infections. Rift Valley fever affects the uvea and posterior chorioretinal area and is associated with permanent visual loss resulting from macular and paramacular scarring, vascular occlusion, and optic atrophy. The study demonstrated for the first time that transient nongranulomatous anterior uveitis is associated with RVF.

Fungal endophthalmitis after surgery or trauma is uncommon. 1-7 We are not aware of any report in the literature ofScytalidium dimidiatum (under the name S synanamorph subspecies of Hendersonula toruloidea) causing eye infection.>" This paper reports a severe case of S dimidiatum -endopthalmitis following trauma. Despite intraocular amphotericin B, miconazole, topical natamycin, and extensive surgical debridement of the involved ocular tissues, the infection persisted and necessitated enucleation.

Climatic droplet keratopathy (CDK) is characterized by a band-shaped pattern of subepithelial opacities and golden-yellow spherules. Recurrence of this disease in corneal grafts has not been reported. We report two cases that developed recurrence of this disease in corneal grafts done for CDK, 3 1/2 years following lamellar penetrating keratoplasty and 6 years following penetrating keratoplasty. This illustrates the possibility of this degenerative disease to recur in a few years if aetiological factors are persistently present.

Background: Eyelids of patients with trachoma may be thickened. This thickening could be attributed to trachomatous changes in the conjunctiva and tarsus. Methods: Biopsies of tarsal plates and palpebral conjunctivae were obtained from 17 upper eyelids of 11 patients with inactive trachoma who underwent posterior tarsotomy procedures for entropion repair. Results: Light microscopy studies showed a thick and compact subepithelial fibrous membrane adherent to the tarsal plate. This membrane caused apparent thickening of the tarsus when measured intraoperatively (range, 1.25–2.00 mm). Other histopathologic findings include atrophy of the meibomian glands with thickening of the acinar basement membrane, loss of goblet cells, retention cysts, and hyaline degeneration of the tarsal plate with focal replacement by adipose tissue. Conclusion: The contraction of the subepithelial fibrous membrane formed by vertically oriented parallel collagen fibers is one of the main factors contributing to the entropion formation.

Kohl is a traditional powder-like mixture used as an eyeliner and to treat eye disease in many Middle and Far East countries. We studied kohl use among 360 individuals selected at random in Riyadh, Saudi Arabia. Kohl was used by 13% of males and 26% of females, especially the elderly and illiterate. Forty percent of females with children applied kohl to the eyes of their children during the first postnatal month. Analysis of five commercially available traditional kohl samples showed that some preparations have a high pH and a high lead concentration (88%), indicating that most preparations are lead-based rather than antimony-based. It is interesting to find that some kohl preparation have a weak antimicrobial effect against Streptococcus, Staphylococcus and Proteus species. The use of lead-based kohl is still a common and serious practice and should be discouraged, especially in children. The role of traditional kohl use in the pathogenesis of common ocular external diseases prevalent in Middle and Far East countries merits in investigation.

Acute angle-closure glaucoma can be triggered by a mature or intumescent cataract, and occurs in eyes with open angles, as well as in those with narrow, occludable angles. This is encountered more in developing countries, where patients present late. They tend to wait until the cataract becomes mature, because it is common belief among these patients that cataracts should not be operated on until vision drops to the level of hand movements or light perception. The authors reviewed the charts of 10 patients who were treated for phacomorphic glaucoma, by first undergoing neodymium: YAG (Nd:YAG) laser iridotomy. In all patients, the acute angle-closure glaucoma attack could be reversed or prevented by the iridotomy, before subsequent cataract extraction. The value of Nd:YAG laser iridotomy in the initial management of phacomorphic glaucoma is discussed.

We report a case of large iris melanocytoma in a child diagnosed by fine needle aspiration biopsy. In this interventional case report, cytologic features typical of melanocytoma were obtained by fine needle aspiration biopsy (FNAB). FNAB can be used in difficult diagnostic cases if a good sample is obtained, this technique has an accuracy of more than 99% in tumors larger than 3mm; however, false-negative and false-positive results may be obtained. Its risk of local spread is very small, an advantage over incisional biopsy. The most common complication is intralesional hemorrhage and hyphema.

The type of corneal ectasia, the presence of breaks in Descemet's membrane, and the success with contact lens wear or penetrating keratoplasty were studied in 61 patients with corneal ectasia and vernal keratoconjunctivitis. There were 53 patients with keratoconus, 5 with pellucid marginal corneal degeneration, 2 with keratoglobus, and 1 with superior corneal thinning. The high rate of hydrops and the corneal ectasia itself may be related to excessive eye rubbing. Success with contact lens wear or penetrating keratoplasty in vernal keratoconjunctivitis patients with keratoconus is less than in patients with keratoconus alone.