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Lojain AlBathi,1 Noura Abouammoh,2 Nayef AlSwaina,3 Hani B AlBalawi,4 Abdullah A Al Qahtani,5 Mohammed Talea,6 Sulaiman M AlSulaiman,7 Marwan A Abouammoh1 1Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia; 2Department of Community and Family Medicine, King Saud University, Riyadh, Saudi Arabia; 3Department of Ophthalmology, College of Medicine, Qassim University, Buraidah, Saudi Arabia; 4Department of Ophthalmology, College of Medicine, Tabuk University, Tabuk, Saudi Arabia; 5Department of Ophthalmology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 6Department of Ophthalmology, Asir Central Hospital, Abha, Saudi Arabia; 7King Khaled Eye Specialist Hospital, Vitreoretinal and Uveitis Divisions, Riyadh, Saudi ArabiaCorrespondence: Marwan A AbouammohDepartment of Ophthalmology, College of Medicine, King Saud University, P. O. Box 245, Riyadh, 11411, Saudi ArabiaEmail dr.abouammoh@gmail.comPurpose: To identify the pitfalls in retinopathy of prematurity (ROP) screening leading to advanced disease at Ministry of Health (MOH) hospitals in Saudi Arabia.Methods: A qualitative deductive content analysis was used to study the phenomena of defects in ROP screening. A retrospective review of medical records of newborns presenting to two tertiary eye care centers with advanced ROP (stage 4 and 5) from January 2012 to June 2019 was completed. An extensive review of the original files at the referring hospitals was conducted, including the general condition and findings of ophthalmic examination and the sequence of follow-up until the infant was discharged/referred. Data analysis was completed using pre-structured categorization matrix.Results: Records of 29 infants with advanced stage ROP were identified. Only 13 medical records were available and obtained. The pitfalls in screening found in the study were failure to refer by the neonatologist, delayed follow-up by the ophthalmologist, failure to follow-up by the ophthalmologist, failure to diagnose by the ophthalmologist, poor documentation in patient files, unavailability of ophthalmologist, family negligence, lack of treatment and delayed referral to a higher center, and progression despite timely screening and management.Conclusion: Although clear ROP screening guidelines are available, implementations of these guidelines are suboptimal. This study showed that the most common defect in screening is physician’s inadequacy and unavailability. A proper network of competent ROP screening physicians in all neonatal intensive care units should be established. Centers for advanced ROP surgery should be allocated to deliver a timely surgical care if needed.Keywords: retinopathy of prematurity screening, pitfalls, content analysis more...

A 37-year-old otherwise healthy male presented with paracentral scotoma in his right eye for 1 day with a history of having unprotected sex with multiple partners. The patient was diagnosed to have acute syphilitic posterior placoid chorioretinitis with multimodal imaging including spectral-domain optical coherence tomography and fundus fluorescein angiography. His condition improved after 2 weeks course of intravenous benzyl penicillin 1.2 g every 4 h in collaboration with infectious disease physician. more...

The Saudi Arabian Retinopathy of Prematurity National Telemedicine programme (SAROP) is a product of the National Committee for Retinopathy of Prematurity (ROP). The program includes ROP telescreening, diagnosis, and management of cases requiring treatment. Digital retinal images and filled ROP software requests were uploaded from 20 level-3 neonatal intensive care units (NICU) in the Kingdom of Saudi Arabia (KSA) to the King Khaled Eye Specialist Hospital server and the ROP telemedicine website. The data were accessed and reported by qualified retinal and pediatric ophthalmologists. Currently, retinal wide-angle digital cameras are available in 20 of the 31 level-3 NICUs of the Ministry of Health, Kingdom of KSA. This telemedicine approach is practical and effective in detecting and managing ROP cases. In the first 2.5 years, encouraging results were noticed with no unfavorable outcomes in the participating NICUs. Technical challenges were resolved promptly to ensure that the program ran smoothly. Therefore, this ideal state-of-the-art ROP telemedicine program could be also applied to similar and neighboring countries. more...

Retinal arterial macroaneurysms with supravalvular pulmonic stenosis (RAMSVPS), also known as Familial Retinal Arterial Macroaneurysms (FRAM) syndrome, is a very rare multisystem disorder. Here, we present a case series comprising ophthalmologic and systemic evaluation of patients homozygous for RAMSVPS syndrome causative IGFBP7 variant. New clinical details on 22 previously published and 8 previously unpublished patients are described. Age at first presentation ranged from 1 to 34 years. The classical feature of macroaneurysms and vascular beading involving the retinal arteries was universal. Follow up extending up to 14 years after initial diagnosis revealed recurrent episodes of bleeding and leakage from macroaneurysms in 55% and 59% of patients, respectively. The majority of patients who underwent echocardiography (18/23) showed evidence of heart involvement, most characteristically pulmonary (valvular or supravalvular) stenosis, often requiring surgical correction (12/18). Four patients died in the course of the study from complications of pulmonary stenosis, cerebral hemorrhage, and cardiac complications. Liver involvement (usually cirrhosis) was observed in eight patients. Cerebral vascular involvement was observed in one patient, and stroke was observed in two. We conclude that RAMSVPS is a recognizable syndrome characterized by a high burden of ocular and systemic morbidity, and risk of premature death. Recommendations are proposed for early detection and management of these complications. more...

To report the outcomes, advantages and disadvantages of a heads-up three-dimensional (3D) visualization system compared to the conventional microscope in pediatric tractional retinal detachment (TRD) surgery secondary to advanced stage retinopathy of prematurity (ROP). Medical records of patients with ROP stage 4 or 5 who underwent surgery for tractional retinal detachment at King Khaled Eye Specialist Hospital between September 2017 and July 2019 were identified and reviewed. Eyes were divided into 2 groups, eyes that underwent surgery with a 3D heads-up platform (3D group) and eyes that underwent surgery with a conventional microscope (conventional group). Data were collected on neonatal history, visual acuity, intraoperative complications and success rates between groups.Eighteen eyes of 14 patients who underwent surgical repair of TRD related to ROP. Postoperative outcomes were compared between 10 eyes (7 patients) in the 3D group and 8 eyes (7 patients) in the conventional group There was no statistically significant difference in success rate between both groups (75% conventional group vs 70% 3D group). Partial or complete reattachment was achieved in 7 eyes in 3D group compared to 6 eyes in conventional group. Lower postmenstrual age at the time of the first surgery and presence of retinal breaks were associated with poorer surgical outcome. Heads up 3D visualization system is feasible in tractional retinal detachment related to ROP with similar success rate and no increased risk of complications when compared to conventional microscope. This system may be advantageous in advanced pediatric tractional retinal detachment surgeries. more...

Purpose: To identify the pitfalls in retinopathy of prematurity (ROP) screening leading to advanced disease at Ministry of Health (MOH) hospitals in Saudi Arabia. Methods: A qualitative deductive content analysis was used to study the phenomena of defects in ROP screening. A retrospective review of medical records of newborns presenting to two tertiary eye care centers with advanced ROP (Stage 4 and 5) from January 2012 to June 2019 was completed. An extensive review of the original files at the referring hospitals was conducted, including the general condition and findings of ophthalmic examination and the sequence of follow-up until the infant was discharged/referred. Data analysis was completed using pre-structured categorization matrix. Results: Records of 29 infants with advanced stage ROP were identified. Only 13 medical records were available and obtained. The pitfalls in screening found in the study were failure to refer by the neonatologist, delayed follow-up by the ophthalmologist, failure to follow-up by the ophthalmologist, failure to diagnose by the ophthalmologist, poor documentation in patient files, unavailability of ophthalmologist, family negligence, lack of treatment and delayed referral to a higher center, and progression despite timely screening and management.Conclusion: Although clear ROP screening guidelines are available, implementations of these guidelines are suboptimal. This study showed the most common defect in screening is physician’s inadequacy and unavailability. A proper network of competent ROP screening physicians in all neonatal intensive care units should be established. Centers for advanced ROP surgery should be allocated to deliver a timely surgical care if needed. more...

Budoor Albabtain,1,2,* Marco Mura,3,4 Patrik Schatz,3,5 Sulaiman M Alsulaiman,3 Wael A Alsakran,3 Valmore A Semidey3,* 1Research Department, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia; 2Department of Ophthalmology, Prince Sultan Medical Military City, Riyadh, Saudi Arabia; 3Vitreoretinal Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia; 4Department of Translational Medicine, University of Ferrara, Ferrara, Italy; 5Department of Ophthalmology, Clinical Sciences, Skane County University Hospital, Lund University, Lund, Sweden*These authors contributed equally to this workCorrespondence: Valmore A SemideyVitreoretinal Division, Department of Ophthalmology, King Khaled Eye Specialist Hospital, P.O. Box 7191, Riyadh, 11462, Saudi ArabiaTel +966-11-482-1234 ext.2655Fax +966 11 4821234 ext.3773Email asemidey@hotmail.comPurpose: To compare the specificity of diagnosing posterior vitreous detachment (PVD) using preoperative optical coherence tomography (OCT) versus intraoperative triamcinolone acetonide (TA) staining in patients undergoing vitrectomy.Patients and Methods: This retrospective cohort study included patients undergoing pars plana vitrectomy for diverse retinal pathologies. Intraoperatively, surgeons evaluated the posterior hyaloid status with TA staining and compared it with preoperative OCT findings.Results: One hundred six patients underwent intraoperative assessments of posterior hyaloid status, with 72% (76/106) of the eyes showing positive staining. Sixty-two patients had also undergone preoperative OCT. Of the patients diagnosed with PVD on preoperative OCT, 50% (15/30) showed positive TA staining intraoperatively. The sensitivity of preoperative OCT assessment was 83.3%, and its specificity was 65.9%.Conclusion: Preoperative OCT imaging is associated with lower sensitivity and specificity for diagnosing PVD when compared to intraoperative TA staining.Keywords: optical coherence tomography, posterior hyaloid, posterior vitreous detachment, vitrectomy, vitreoschisis, triamcinolone acetonide more...

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

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

Purpose: To report a blue laser-induced full thickness macular hole (FTMH) with delayed spontaneous closure without surgical intervention. Observations: A 14-year old male developed full thickness macular hole after momentary exposure to a high-power handheld blue laser device. The macular hole closed spontaneously over a long period of observation. Conclusion: Despite an initial enlargement in size, small FTMH caused by blue lasers may close spontaneously over an extended period of observation. Keywords: Blue laser, Full thickness macular hole, Spontaneous closure more...

Purpose: There has been a recent increase in accidental retinal injuries due to the careless use of handheld laser devices. The scenarios under which these incidents occur suggest a lack of awareness of the sight-threatening hazards of some handheld lasers. This study aimed to assess knowledge of the population to plan awareness programs and establish protective health policies. Methods: This observational cross-sectional study used a newly-developed, validated, and pilot-tested questionnaire to survey attendees of football matches in Saudi Arabia between September to October 2018. Results: Five-hundred and sixty-nine attendees were surveyed, and 76% of respondents knew laser pointers were harmful and could damage the eye. However, 73% of respondents did not think that the blue laser was dangerous, indicating poor awareness regarding this particular laser. Only 38% knew which ocular structure is most commonly damaged, and 15.6% did not realize that brief exposure can cause vision loss. Females had better knowledge compared to males. Respondents between 25 and 40 years old, females, and married individuals had the highest levels of a positive attitude. There was no statistically significant difference in the mean knowledge score between those in the medical field and other fields (P = 0.5). Conclusion: There is an inadequate knowledge of protective measures against handheld lasers. However, there's an overall positive attitude towards spreading awareness about this issue. Yet, targeted awareness campaigns are still needed in addition to more strict government laws to prevent importing or using high-powered handheld laser pointers. more...

Ocular involvement in pemphigus vulgaris (PV) is relatively rare. The conjunctiva and eyelids are considered the most common affected sites in ocular pemphigus. Scleritis is rarely reported as a manifestation of PV. We present a case report of anterior scleritis as a manifestation of PV and its response to rituximab therapy. more...

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

A 10-month-old infant with the diagnosis of retinal cavernous hemangioma involving the macula presented with an outward deviation of the right eye that has been noticed by her parents. Examination revealed a clearing vitreous hemorrhage, and grape-like clusters filled with blood in the posterior pole. After 4 cycles of intravenous infliximab over the period of 3 months, no evident change was noted on the size of the cavernous hemangioma. more...

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