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Background: The ophthalmology workforce is an integral component of any health care system. However, the demand for eye care has imposed a heavy burden on this system. Hence, this study aimed to estimate the trends, demographic characteristics, distribution, and variation between Saudi and non-Saudi ophthalmologists and the future challenges of the ophthalmology workforce in the Kingdom of Saudi Arabia (KSA)., Methods: This study was conducted in the KSA and included ophthalmologists practicing from 2010 to 2023. From the Saudi Commission for Health Specialties, we obtained the number, gender, nationality, and rank of ophthalmologists. The geographic distribution of ophthalmologists in the KSA was obtained from the Ministry of Health Statistical Yearbook 2021., Results: As of January 2023, the KSA had a total of 2608 registered ophthalmologists, with approximately 81.06 ophthalmologists per 1,000,000 people. Only 38% of all ophthalmologists in the country were Saudis. The percentage of Saudi female graduates increased from 13.3% to 37.2% over 12 years [Sen's estimator of slope for median increase per year = 1.33 (95% CI 1.22-1.57) graduates; trend test P < 0.001). Additionally, we found that the geographic distribution of ophthalmologists varied (test for homogeneity of rates, P < 0.0001), with the larger regions having a higher concentration of ophthalmologists than the smaller regions (75.6 in Riyadh versus 42.8 in Jazan per 1,000,000 people). However, the World Health Organization's target for the ophthalmologist-to-population ratio has been achieved in all 13 health regions of KSA., Conclusion: The recommended ophthalmologist-to-population ratio has been achieved in the KSA, and the number of Saudi ophthalmologists has almost doubled over the past 8 years. However, the majority of ophthalmologists are still non-Saudi, as Saudi ophthalmologists constitute approximately one-third of the ophthalmology workforce in the KSA. The geographical distribution of ophthalmologists varies, which might affect access to care in peripheral regions. In response to the growing demand for eye care in the KSA, several more effective measures might need to be considered., (© 2024. The Author(s).)

Purpose: To report a case of Enterobacter cloacae (E. cloacae) keratitis in a patient who underwent corneal crosslinking (CXL) for progressive keratoconus., Observations: A 19-year-old female underwent CXL for keratoconus in her left eye. The patient neglected her post-procedure medications and missed the follow-up visit. Subsequently, she presented on day-10 post CXL with redness and pain in the treated eye. Clinical examination revealed a ring-shape infiltrate measuring 7.8 mm in diameter. Culture indicated the presence of E. cloacae. Treatment with gentamicin failed after the emergence of resistance. The patient was successfully treated with amikacin and moxifloxacin over several weeks., Conclusions: Judicious antibiotic selection is crucial to limit the emergence of resistance in multidrug-resistant (MDR) pathogens. All patients need to be educated about their role in the management plan.

Purpose: To compare the outcomes of fibrin glue versus sutures in pterygium surgery with amniotic membrane transplantation., Methods: A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses Guidelines. An electronic search identified all studies comparing the outcomes of using fibrin glue versus sutures in pterygium surgery with amniotic membrane transplantation. Conjunctival inflammation, postoperative pain and discomfort, pterygium recurrence, pyogenic granuloma, and surgical time were primary outcome measures. Secondary outcome measures included amniotic membrane transplant outcomes, time to recurrence, graft loss, and subconjunctival hemorrhage. Fixed and random-effects models were used for the analysis., Results: Four studies enrolling 180 patients were identified. Conjunctival inflammation (odds ratio [OR] 0.21, P = 0.0005) demonstrated a significant difference favoring the fibrin glue group. Despite the trend favoring the use of fibrin glue, there were no significant differences in terms of postoperative pain and discomfort (OR = 0.46, P = 0.25), pterygium recurrence (OR = 0.74, P = 0.48), pyogenic granuloma (OR = 0.47, P = 0.38), and surgical time (mean difference = -17.52, P = 0.13). For secondary outcomes, fibrin glue had significantly fewer cases of graft loss compared with sutures. No statistically significant difference was found in amniotic membrane graft outcomes, time to recurrence, and subconjunctival hemorrhage., Conclusion: Fibrin glue is comparable to the sutures used in pterygium surgery with amniotic membrane transplantation as it significantly improves conjunctival inflammation and does not increase postoperative pain and discomfort, pterygium recurrence, pyogenic granuloma, and surgical time., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Saudi Journal of Ophthalmology.)

Purpose: The aim of this study was to compare the outcomes of 18 mW/cm 2 (5 minutes) versus 9 mW/cm 2 (10 minutes) accelerated corneal collagen cross-linking protocols in patients with progressive keratoconus., Methods: A systematic review and meta-analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and electronic information was searched to identify studies comparing the outcomes of 5- versus 10-minute protocols in patients with progressive keratoconus. Mean changes in uncorrected visual acuity, best-corrected visual acuity, cylinder (diopters), thinnest corneal thickness, corneal keratometry values (K1 and K2), corneal high-order aberration (HOA), spherical aberration, coma, and trefoil were the primary outcome measures. Secondary outcome measures included the mean change in central corneal thickness and postoperative complications. Random effects modeling was used for the analysis., Results: Four studies that enrolled 329 eyes were included. The 10-minute protocol had significantly improved outcomes compared with the 5-minute protocol for the mean changes in K1 and K2 ( P < 0.00001), corneal total HOA ( P = 0.0002), and corneal coma ( P = 0.00001). However, no statistically significant differences were found between the 2 protocols in uncorrected visual acuity, best-corrected visual acuity, cylinder, thinnest corneal thickness, spherical aberration, or trefoil. The 5-minute protocol was associated with a significantly lower mean change in the central corneal thickness for secondary outcomes. In addition, no significant differences were found between the 2 protocols for postoperative complications., Conclusions: The 10-minute protocol had better K1, K2, and HOA outcomes than the 5-minute protocol, but no statistically significant differences in the other outcomes., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To evaluate the characteristics of patients with post-keratoplasty complications and their presentation at an emergency center., Design: Retrospective one-armed cohort study., Methods: Data were evaluated on patients who underwent corneal grafts in 2019 and presented to an emergency unit. Data were collected on patient demographics, presenting symptoms, clinical details, diagnosis at emergency visit, final diagnosis, best-corrected visual acuity (BCVA) at presentation and at the last follow-up after management. Severe visual impairment (SVI) and graft rejection were tested for correlations to other factors., Results: The study sample was comprised of 149 eyes of 124 patients with a mean age of 27.5 years. Keratoconus was the indication for keratoplasty in 94 (75.8%) patients. The main presenting symptoms were pain 57 (38.3%) and red eye in 52 (34.9%) patients. The median interval between emergency visit and keratoplasty was 1.6 years. There were 63 (42.3%) patients who had emergency visits due to suture-related problems. The rates of SVI and graft rejection at the time of discharge after managing emergencies in eyes with previous keratoplasty were 14.1% (95% CI 8.5; 19.7) and 13.4 (95% CI 7.9; 18.9), respectively. Keratoconus (OR = 22.8) and young age (P < 0.001) were negatively associated with SVI after management., Conclusion: Patients with keratoplasty are at high risk for severe vision loss and should be counseled to seek urgent eye care for early detection and management of sight-threatening complications to improve graft survival and vision., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Aim: To evaluate the incidence and severity of ocular graft versus host disease (oGVHD) in patients who underwent allogeneic stem cell transplant (SCT) in King Abdul-Aziz Medical City, Saudi Arabia., Methods: This is a retrospective cohort study conducted in King Abdul Aziz Medical City on patients who underwent allogeneic hematopoietic cell transplant (allo-HCT) from 2010 to 2017. The ocular examination findings including visual acuity, meibomian gland dysfunction, corneal and conjunctival staining with severity, corneal scarring, tear film meniscus and breakup time, anterior and posterior segment examination findings, intraocular pressure, treatment given, punctual plugs used or not, and follow up response were collected., Results: The five years cumulative incidence of oGVHD among post-transplant patients was 56.98% (95%CI 38.6%-71.7%). The potential risk factors assessed for developing ocular manifestation were age, gender, donor's age, donor gender mismatch CD3 and CD34 infusion, while none of the correlates were identified as statistically significant risk factors of developing ocular manifestation. However, the incidence was statistically significantly different between patients diagnosed with acute myelocytic leukemia and acute lymphocytic leukemia ( P =0.038). The mean latent period to develop ocular symptoms was 20.5mo. All patients had variable degree of dry eyes. None of the patients developed any posterior segment complication., Conclusion: The incidence of oGVHD is low in King Abdul-Aziz Medical City. This can be attributed to the preconditioning and immunosuppressive regime., (International Journal of Ophthalmology Press.)

Aim: To evaluate the causes of phakic implantable collamer lens (ICL) exchange/explantation in patients with and without keratoconus (KC) at two tertiary hospitals in Riyadh, Saudi Arabia., Methods: A retrospective chart review of all patients who underwent ICL (model V4c with central port) exchange/explantation was performed using the electronic medical record systems. All available preoperative and postoperative data were documented for each patient., Results: Over 7y, 2283 ICL implantation procedures were performed; 46 implants (2%) required exchange (21 implants)/explantation (25 implants), of which 14 cases (30.4%) were patients with KC. Indications for ICL exchange/explantation in non-KC group were vault measurement, cataract formation, increased intraocular pressure, inaccurate refraction, and patient dissatisfaction in 22 (68.75%), 4 (12.5%), 3 (9.37%), 2 (6.25%), and 1 (3.12%) case, respectively. The most common indication for ICL exchange/explantation in the KC group was inaccurate vault sizing in 11 patients (78.57%), inaccurate refraction in 2 patients (14.28%), and patient dissatisfaction postoperatively in 1 (7.14%) case., Conclusion: ICL implantation results in predictable refractive outcomes over the long term with exchange/explantation rates comparable to previous literature. Improper vault size is the most common cause of ICL exchange/explantation among patients with or without KC., (International Journal of Ophthalmology Press.)

Purpose: To determine the prevalence of refractive errors among Saudi adults in Riyadh, Saudi Arabia., Methods: A cross-sectional study was conducted targeting healthy Saudi adults (20-40 years old) at two major gatherings in Riyadh, Saudi Arabia from December 2018 to January 2019. Refractive errors were measured, and data pertaining to age, sex, region of origin, and spectacle use was collected. Clinically significant myopia was defined as SE ≥ -0.50 D, hyperopia as SE ≥ 0.50D, and astigmatism as cylindrical error ≥ 0.50D. Refractive error measurements were assessed using Topcon's Auto-Kerato-Refractometer, KR-800., Results: A total of 660 adult individuals (1,319 eyes) were included in this study, of which 321 participants (48.7%) were found to be myopes, 167 subjects (25.2%) were hyperopes, and 438 individuals (66.3%) had astigmatism. With regards to correlations, myopia was highly correlated with being male ( P -value = 0.036), belonging to age group 20-25 years ( P -value = 0.033), originating from the northern regions of Saudi Arabia ( P -value <0.001). Similarly, hyperopia was significantly correlated with being male ( P -value = 0.048), age groups 20-25 years ( P -value = 0.04), and 31-35 years ( P -value = 0.011) and was higher in people from northern region ( P -value = 0.011). In contrast, astigmatism was only found to be correlated with age group 36-40 years ( P -value = 0.002). Additionally, 71.7% of myopic participants and 76.1% of astigmatic individuals opted not to wear spectacles ( P -value <0.001)., Conclusion: In this study, the refractive error with the highest prevalence among Saudis was astigmatism, followed by myopia and hyperopia. Gender, region of origin, and spectacle wear were all observed to be highly correlated with higher rates of refractive error., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Saudi Journal of Ophthalmology.)