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Sihem Lazreg,1 Mohamed Hosny,2 Muhammad A Ahad,3 Mazen M Sinjab,4 Riadh Messaoud,5 Shady T Awwad,6 Antoine Rousseau7 1Ophthalmology Cabinet, Blida, Algeria; 2Refractive and Cornea Service, Cairo University Hospitals, Cairo, Egypt; 3Department of Ophthalmology, Anterior Segment Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia; 4Dr Sulaiman Al Habib Hospital, DHCC, Dubai, United Arab Emirates; 5Department of Ophthalmology, Tahar SFAR University Hospital, Mahdia, Tunisia; 6Department of Ophthalmology, American University of Beirut - Medical Center, Beirut, Lebanon; 7Department of Ophthalmology, Bicêtre Hospital, Paris-Saclay University, Le Kremlin-Bicêtre, FranceCorrespondence: Antoine Rousseau, Pierre Testas Building, Bicêtre Hospital, 78 Rue du Général Leclerc, Le Kremlin-Bicêtre, 94270, France, Tel +33145213690, Email arousseau1010@gmail.comAbstract: In the Middle East and Northern Africa (MENA), dry eye disease (DED) is often misdiagnosed or overlooked. This review summarizes a series of conversations with ophthalmologists in the region around a variety of climatic, lifestyle, and iatrogenic factors that contribute to specific features of DED in the MENA region. These considerations are further classified by patient lifestyle and surgical choices. All statements are based on discussions and formal voting to achieve consensus over three meetings. Overall, a deeper understanding of the disease characteristics of DED specific to MENA can better guide local eyecare practitioners on appropriate management and follow-up care. Additionally, population-based studies and patient and physician education on ocular surface diseases, together with the use of culturally appropriate and language-specific questionnaires can help ease the public health burden of DED in this region.Keywords: ocular surface, regional clinical practice, epidemiology, treatment, patient outcomes

Mazen M Sinjab,1,2 Roy S Rubinfeld,3,4 Kirsten Wagner,5,6 Edward C Parsons Jnr,7 Arthur B Cummings,8 Michael W Belin9 1Dr. Mazen Eye Clinic, Medcare Hospitals and Centres, Dubai, United Arab Emirates; 2Al Zahra Medical Group, Damascus, Syria; 3Department of Ophthalmology, Georgetown University Medical School/Washington Hospital Center, Washington, DC, USA; 4Re:Vision Private Practice, Rockville, MD, USA; 5Department of Ophthalmology, Medstar Georgetown University Hospital, Washington, DC, USA; 6Department of Ophthalmology, Medstar Washington Hospital Center, Washington, DC, USA; 7CXL Ophthalmics, Encinitas, CA, USA; 8Wellington Eye Clinic, Dublin, Ireland; 9Department of Ophthalmology, University of Arizona, Tucson, AZ, USACorrespondence: Roy S Rubinfeld 3131 Connecticut Ave, NW, #2809, Washington, DC, 20008, USAEmail Doctor@revisedeye.comPurpose: To assess the effectiveness of a novel treatment for patients with advanced corneal ectasia and loss of visual acuity (VA). Conductive keratoplasty (CK) is performed to improve VA followed by epithelium-on (epi-on) corneal crosslinking (CXL) to stabilize the cornea after CK.Methods: Retrospective, exploratory cohort study. Patients with keratoconus or postsurgical ectasia and best spectacle-corrected distance VA (CDVA) ≤ 20/40 were included. Conductive keratoplasty was performed (ViewPoint CK System, Refractec, Inc., Bloomington, MN); followed a day later by epi-on CXL (CXLUSA/CXLO, Bethesda, MD/CXLO Encinitas, CA). Measures included uncorrected distance visual acuity (UDVA) and CDVA, as well as refractive and tomographic measures and tomographic indices.Results: Data from 50 eyes of 45 patients were analyzed. Mean follow-up was 15.1 ± 12.2 months (range: 2 to 51). Overall, UDVA and CDVA improved postoperatively. Subjective refraction and tomographic metrics did not show consistent changes, but changes in tomographic indices were associated with treatment follow-up time. At the 1-year visit, mean UDVA significantly improved over baseline (P = 0.009) by approximately 3 lines; mean CDVA improved significantly (P = 10− 5) by approximately 2 lines. No eye lost lines of CDVA. Change in the Index of Surface Variance (ISV) was associated with treatment, and the D-Index trended over follow-up time.Conclusion: Conductive keratoplasty with a proprietary epi-on CXL treatment improved vision in patients with advanced ectasia This CK/epi-on CXL treatment offers the possibility of improved VA for patients with compromised vision due to ectasia.Keywords: conductive keratoplasty, CK, corneal crosslinking, crosslinking, keratoconus, ectasia, thermokeratoplasty

This article is a historical and prospective review of keratoconus and ectatic corneal diseases. It covers definitions and terminology, the prevalence of keratoconus, predisposing factors, diagnosis, differential diagnosis, management, classifications, and progression criteria. It highlights other aspects of the disease that are usually over-missed, including the psychological, social, and economic impact. This review presents the information chronically in terms of the first author. It concludes by possessing the challenges and difficulties that are still to be overcome and suggests a plan., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Oman Ophthalmic Society.)

Purpose: The aim was to investigate the prevalence and risk factors of refractive errors (REs) and the effective spectacle coverage in Emiratis and non-Emiratis in Dubai., Design: The Dubai Eye Health Survey was a population-based cross-sectional study of participants aged 40 years or older., Methods: Distance and near visual acuity (VA), and noncycloplegic automated refraction were tested according to a standardized protocol. Distance VA was tested using the Early Treatment Diabetic Retinopathy Study (ETDRS) logMAR chart at 3 m and near VA was measured using the near vision logMAR chart at 40 cm under ambient lighting. Myopia was defined as spherical equivalent of refraction of less than -0.50 diopters (D), and hypermetropia as spherical equivalent of more than +0.50 D. Astigmatism was defined as cylinder power of 0.5 D or greater. Effective spectacle coverage for distance vision was computed as met need/(met need+unmet need+under-met need)×100%. Multivariable logistic regression models were used to examine associations between sociodemographic factors and RE., Results: The authors included 892 participants (446 Emiratis and 446 non-Emiratis) in the analysis. The prevalence of hypermetropia was 20.4% [95% confidence interval (CI): 16.8%-24.4%] in Emiratis and 20.6% (95% CI: 20.0%-24.7%) in non-Emiratis. The prevalence of myopia and high myopia was 27.4% (95% CI: 23.3%-31.7%) and 1.8% (95% CI: 0.8%-3.5%) in Emiratis, and 19.5% (95% CI: 15.9%-23.5%) and 0.9% (95% CI: 0.2%-2.3%) in non-Emiratis, respectively. High education (P=0.02) and not currently working (P=0.002) were risk factors of myopia in non-Emiratis only. The prevalence of astigmatism was 7.4% (95% CI: 5.1%-10.2%) in Emiratis and 1.6% (95% CI: 0.6%-3.2%) in non-Emiratis. This prevalence was higher in individuals aged over 60 years (P<0.001) and men (P=0.014) among Emiratis. The prevalence of anisometropia and uncorrected presbyopia was 11.4% (95% CI: 8.6%-14.8%) and 0.7% (95% CI: 0.1%-2.0%) in Emiratis, and 9.2% (95% CI: 6.7%-12.3%) and 0.4% (95% CI: 0.05%-1.6%) in non-Emiratis, respectively. The effective spectacle coverage was 62.3% (95% CI: 54.0%-70.6%) and 69% (95% CI: 60.5%-77.5%) in Emiratis and non-Emiratis, respectively., Conclusions: A high proportion of Emiratis and non-Emiratis was affected by RE without optimal effective spectacle coverage, highlighting the imperativeness of intervention to alleviate the burden. The findings may help facilitate evidence-based policymaking concerning the delivery of eye care services and allocation of medical resources in Dubai., (Copyright © 2022 Asia-Pacific Academy of Ophthalmology. Published by Wolters Kluwer Health, Inc. on behalf of the Asia-Pacific Academy of Ophthalmology.)

Purpose: To study the prevalence, causes, and risk factors of visual impairment (VI) among the Dubai Emiratis and non-Emiratis., Methods: The survey was a population-based cross-sectional eye health study conducted 2019-2020. Cluster sampling was used to randomly select local (Emirati) and expatriate (non-Emirati) Dubai residents aged 40 years and older. Ocular examinations were conducted in selected eye clinics to determine the visual acuity (VA) and cause(s) of VI if any. Trained nurses, optometrists, and ophthalmologists did the examinations. VA was measured using ETDRS visual chart. The World Health Organization VI and blindness definitions and classifications for the cause(s) of VI were used., Results: A total of 892 participants were included in the final analysis. The mean age [SD] was 52.09 [9.48] years, with 55.8% as males. Prevalence of presenting mild, moderate, and severe VI was 4.7% (2.94-7.11%), 1.8% (0.78-3.5%), and 0% for Emiratis, and 3.6% (2.06-5.76), 1.6% (0.63-3.21), and 0% for non-Emiratis, respectively. Four Emirati participants were blind, with a prevalence of 0.9% (0.25%-2.28%). Men had lower likelihood of VI than women (odds ratio [OR] (95% CI): 0.42 (0.24-0.77)) after adjustment for covariates. Diabetes (OR (95% CI): 1.91 (1.04-3.52)) was an independent risk factor for VI. Higher education level was associated with a lower likelihood of VI (OR (95% CI): 0.34 (0.13-0.89). Leading causes of VI among Emiratis were uncorrected refractive error (52%) and cataract (17.2%). Glaucoma, optic atrophy, and absent globe were the causes of blindness., Conclusions: Prevalence of VI is comparably low with leading causes readily treatable. An effective strategy to improve spectacle correction and cataract services would reduce the VI burden., Competing Interests: The authors have no financial or other conflicts of interest concerning this study., (Copyright © 2022 Manal O. Taryam et al.)

Purpose: To evaluate the safety and efficacy of intrastromal corneal ring segments (ICRS) implantation followed by same-day topography-guided photorefractive keratectomy (PRK) and ultraviolet-A/riboflavin collagen cross-linking (CXL) in patients with low to moderate keratoconus., Methods: Patients with low to moderate keratoconus and contact lens intolerance were included in the study. All patients first underwent femtosecond laser-enabled placement of ICRS (Keraring, Mediphacos) (first step). Same-day topography-guided PRK and CXL (second step) were subsequently performed in all patients after the refraction was stable (average 6 months [range: 3 to 11 months])., Results: Thirteen eyes from 13 patients were included in the study. Based on values before the first step and 6 months after the second step, significant improvements were noted in uncorrected distance visual acuity (0.7±0.32 logMAR vs 0.08±0.08 logMAR), corrected distance visual acuity (CDVA) (0.16±0.19 logMAR vs 0.02±0.04 log-MAR), sphere (-3.65±3.08 diopters [D] vs 0.06±1.6 D), astigmatism (-3.31±1.5 D vs -0.98±0.75 D), average K (47.28±1.99 D vs 41.42±3.22 D), and coma (2.36±1.23 μm vs 1.47±0.68 μm) (P<.05). Approximately 63% of eyes gained ⩾2 lines of CDVA, whereas no change in CDVA was reported in ∼27% of eyes. No eyes lost lines of CDVA., Conclusions: The combination of ICRS implantation followed by sequential same-day topography-guided PRK/CXL may be a reasonable option for improving visual acuity in patients with low to moderate keratoconus., (Copyright 2013, SLACK Incorporated.)

Purpose: To study the tomographic features of pellucid-like keratoconus (PLK), and to report a new sign on the pachymetry map (PM) in pellucid marginal degeneration (PMD)., Patients and Methods: A retrospective descriptive case series was performed in Damascus University in 2011. Clinical and tomographic findings of 15 eyes (9 patients) that had the claw pattern of the anterior sagital map (ASM) were reviewed. Patients were distributed into two groups: (1) 4 eyes were considered PMD since they had inferior corneal thinning on both slitlamp biomicroscopy and PM; (2) 11 eyes were considered as PLK since they did not show inferior corneal thinning. Patients were studied using slitlamp biomicroscopy and Scheimpflug-based tomography (Pentacam HR). The ASM, anterior elevation map (AEM) and PM were analyzed and compared to study the "kissing birds" sign, the "bell" sign, and cone location., Results: Patients' average age was 25.93±8.05 (16-44 years). In total, 60% of patients were male. In group 1, the AEM in the best fit sphere (BFS) mode revealed no kissing birds sign, and the cone was central in 1 eye (25%) and paracentral in 3 eyes (75%). PM showed the bell sign in 4 eyes (100%). In group 2, the AEM in the BFS mode revealed the kissing birds sign in 2 eyes (18.2%), and the cone was central in 1 eye (9.1%), paracentral in 8 eyes (72.7%) and peripheral in 2 eyes (18.2%). PM didn't show the bell sign in any eye., Conclusion: The claw pattern on the ASM is not a hallmark of PMD; it can be seen in PLK. Cone location does not relate to diagnosis. The "bell" sign on the PM is a deferential diagnostic sign in PMD.

Purpose: To evaluate 1-year visual and topographic outcomes and safety and efficacy of corneal collagen cross-linking (CXL) combined with topography-guided photorefractive keratectomy (TG-PRK) to achieve near emmetropia in eyes with low-grade keratoconus., Methods: Twenty-two eyes from 15 patients (11 women, 4 men) were included in a prospective, nonrandomized, noncontrolled clinical study. Mean patient age was 26.6±6.07 years (range: 19 to 40 years). Inclusion criteria were low-grade keratoconus with evidence of progression, transparent cornea, corrected distance visual acuity (CDVA) 0.8 (decimal) or better, corneal thickness >440 μm, and maximum keratometry readings (K-max) <51.00 diopters (D). All patients underwent simultaneous TG-PRK with CXL. Study parameters were uncorrected distance visual acuity, CDVA, manifest refractive error, manifest and topographic (corneal) astigmatism, patient satisfaction, and efficacy and safety of the treatment. Follow-up was 1 year., Results: After 1 year, statistically significant improvement was noted in all study parameters (P<.01). The safety and efficacy indices were 1.6 and 0.4, respectively. Patient satisfaction questionnaire showed that 91% were satisfied, 9% were not completely satisfied but believed they improved, and none were dissatisfied. Corneal topography demonstrated significant improvement in 55%, improvement in 36%, and minor improvement in 9% of cases. No cases progressed as evidenced by keratometry readings., Conclusions: Simultaneous TG-PRK with CXL is an effective and safe treatment with remarkable visual and topographic outcomes in patients with low-grade keratoconus who meet the recommended inclusion criteria., (Copyright 2012, SLACK Incorporated.)