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   Table of Contents - Current issue
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April-June 2020
Volume 34 | Issue 2
Page Nos. 77-150

Online since Monday, December 28, 2020

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ORIGINAL ARTICLES  

A prospective randomized double-blinded study of dexmedetomidine versus propofol infusion for orbital surgeries p. 77
Bipasha Mukherjee, Varsha Backiavathy, R Sujatha
DOI:10.4103/1319-4534.305021  
PURPOSE: Orbital surgeries are traditionally taken up under general anesthesia. Local anesthesia combined with moderate sedation can also be considered as an alternative option. This study was performed to compare the safety and efficacy of dexmedetomidine and propofol infusion for orbital surgeries under local anesthesia. METHODS: Twenty patients undergoing orbital surgery by a single surgeon were enrolled in this prospective randomized study. Selected patients were randomly administered dexmedetomidine (Group D) or propofol (Group P). Hemodynamic and respiratory effects, sedation levels, recovery profile, analgesic properties, and satisfaction levels of the patients and the surgeon were assessed. RESULTS: There was a significant decrease in mean arterial pressures following drug administration compared to initial measurements in both the groups. However, a statistically significant decrease in heart rate was observed only in Group P. The sedation score at the end of loading dose was 3.3 ± 0.82 in Group D and 2.5 ± 0.52 in Group P and this difference was also statistically significant (P value-0.027). The surgeon's satisfaction score was 6.5 ± 0.71 in Group D and 5.6 ± 1.07 in Group P (P value – 0.045). There were no statistically significant differences observed in patients' satisfaction, pain, and anxiety scores in either group. No major hemodynamic changes or complications were noted in either of the groups. CONCLUSION: Dexmedetomidine, in comparison to propofol, provides better sedation levels with good hemodynamic stability. It also offers better surgeon satisfaction, thus providing a useful alternative for general anesthesia in selective patients undergoing orbital surgery.
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Iris extramedullary hematopoiesis in choroidal melanoma p. 82
Beatrice Gallo, Rana’a T Al-Jamal, Caroline Thaung, Victoria M L. Cohen
DOI:10.4103/1319-4534.305034  
PURPOSE: Extramedullary hematopoiesis (EMH) usually occurs in patients with loss of bone marrow hematopoietic function, and in a vast majority of cases, it involves the liver, the spleen, or the lymph nodes. We report EMH in the iris of patients enucleated for choroidal melanoma (CM). METHODS: We report a series of three patients with CM, two treated with primary enucleation and one with secondary enucleation. RESULTS: Histopathology revealed EMH in the iris of all patients. CONCLUSION: EMH of the iris can be associated with CM in the absence of any hematological or systemic disorders. To the best of our knowledge, our work is the first report of this abnormal histopathological finding.
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Knowledge, attitude and practice regarding diabetic retinopathy screening and its management among diabetic patients at a private hospital of Riyadh, Saudi Arabia p. 85
Tariq Al-Asbali, Sakhr A Aldawari, Ibrahim A Alzahim, Hiba Alalawi, Rajiv Khandekar, Nancy M Lotfy
DOI:10.4103/1319-4534.305040  
PURPOSE: We present the KAP levels and the determinants for diabetic retinopathy (DR) screening and management at a private hospital in Riyadh, Saudi Arabia. METHODS: A chart review was performed of DM patients to collect the demographics and diabetes related information in June to December 2017. A close ended questionnaire was used that queried knowledge (7), attitude (5) and practice for DR screening (7). RESULTS: Two hundred participants were interviewed half from endocrinology unit and half from the eye clinic. An excellent knowledge of the ophthalmic effects of diabetes was noted in 91 [45.5% (95% Confidence Interval CI 38.6–52.4) of participants. Thirty-eight [19% (95% CI 13.6–24.4)] participants had a positive attitude. None had an excellent grade of practice and poor practice was noted in 168 [74% (95% CI 78.9–89.1)] participants. Longer duration of DM (P=0.07) and systemic complications (P=0.06) were associated with good knowledge. Attitude was not significantly associated with any determinants. Good practice was associated with the presence of systemic complications of DM (P<0.01) and those recruited to the eye clinic (P= 0.06). Only 35% of patients had undergone an annual DR screening. Only 4 patients had a history of laser treatment. CONCLUSION: The KAP of diabetic patients regarding DR screening and management is less than desired. Establishing protocols and public health promotion activities directed at early detection and management are urgently needed in private sectors of Saudi Arabia.
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Inverting peripheral hyperopic defocus into myopic defocus among myopic schoolchildren using addition power of multifocal contact lens p. 94
Kareem Allinjawi, Sharanjeet Kaur, Saadah M Akhir, Haliza A Mutalib
DOI:10.4103/1319-4534.305035  
PURPOSE: The purpose was to determine the minimum near-addition power needed using Proclear® multifocal D-Design contact lens (adds: +1.50 D, +2.50 D, +3.00 D, and +3.50 D) to invert the pattern of relative hyperopic defocus in the peripheral retina into relative myopic defocus among the eyes of myopic schoolchildren. METHODS: Twenty-seven right eyes (24 females and 3 males) of 27 myopic schoolchildren aged between 13 and 15 years were included in this study. The measurements of central refraction, peripheral refraction (between 35° temporal and 35° nasal visual field in 5° steps), and lag of accommodation were conducted using the Grand-Seiko WR-5100K open-field autorefractometer initially without correction (WC), followed by with correction using four different addition powers of Proclear® multifocal D-Design contact lens in random sequence. Axial length was measured using a handheld probe ultrasound A-scan (Tomey AL-2000). RESULTS: The relative peripheral refractive error showed high hyperopic defocus of +1.08 ± 1.24 D at 35° nasal and +1.06 ± 1.06 D at 35° temporal visual field WC. All Proclear multifocal contact lenses (MFCLs) decreased the peripheral hyperopic defocus with increasing addition powers (F [2.938, 47.001] = 13.317, P < 0.001). However, only +3.00 D addition and +3.50 D addition (P = 0.001) could invert the peripheral hyperopic defocus into peripheral myopic defocus. Apart from that, the +3.00 D addition lens showed the lowest lag of accommodation (+1.10 ± 0.83 D) among the other MFCL adds (P = 0.002). CONCLUSION: A +3.00 D addition Proclear MFCL is the optimal addition power that can invert the pattern of peripheral hyperopic defocus into myopic defocus.
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Management outcomes of canalicular laceration in children p. 101
Fatimah Alhammad, Alicia Galindo-Ferreiro, Rajiv Khandekar, Osama Al-Sheikh, Fatimah Alzaher, Silvana Schellini
DOI:10.4103/1319-4534.305041  
PURPOSE: To report the epidemiological data, clinical profile, management, and outcomes of canalicular lacerations in the pediatric age group in a tertiary eye care hospital in Saudi Arabia. METHODS: This retrospective study evaluated pediatric patients who underwent canalicular laceration repair in the last 15years at King Khalid Eye Specialist Hospital (KKESH), Saudi Arabia. Demographics, causes of injury, type of trauma, surgical approach, and outcomes were analyzed. The success of repair was defined as the absence of epiphora after canaliculus repair with negative dye disappearance test (DDT). Success within subgroups was compared. P<0.05 was considered statistically significant. RESULTS: The study sample was comprised of 43 patients, with a median age of 6.35years (range, 1.77–17.96years). Most of the patients were males (69.8%). Sharp objects were the most common cause of canalicular laceration (46.5%), being 9 (20.9 %) caused by a metallic clothing hanger. Lower canaliculus was involved in 65.1%, upper canaliculus in 32.6%, and both canaliculi in 2.3% of patients. Canaliculus repair was performed with a bicanalicular stent in 58.1 % and monocanalicular stent in 41.9 % of patients.The success rate and risk of complications using bicanalicular or monocanalicular stent did not differ (P=0.065). Functional success was achieved in 87.5% of patients. CONCLUSION: Canalicular laceration is common in male children, mainly affecting the lower canaliculus. There was no difference in success rate between monocanalicular and bicanalicular stent. As canalicular laceration could be related to social determinants, the main causes should be highlighted in community health education initiatives.
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Comparing experiential versus conventional learning on knowledge retention for teaching surgery to medical graduates p. 107
Majed Alkharashi
DOI:10.4103/1319-4534.305042  
PURPOSE: The study aims to evaluate and see if experiential learning theory for teaching cataract surgery can improve the ability of students to retain more knowledge compared to the classical or traditional way of teaching. METHODS: A pre and post control group design of 32 graduates was conducted in 2016 at King Saud University, Riyadh, Saudi Arabia to examine the effect of experiential learning as an applicable way for teaching cataract surgery. The total of graduates including males and females were divided into control and experimental groups to which the educational materials about cataract surgery were presented as a lecture and as wet lab session respectively. All the data collected were entered in SPSS version 22 for analysis and a P≤0.05 was considered significant. RESULTS: Both control and experimental groups showed good retention rate of knowledge. However, the gain of knowledge was more in the Wet lab group. The scores mean increased more than 5 points in this group compared to 2.5 points only in the lecture groups. CONCLUSION: Both teaching modalities were effective in improving the knowledge rate of the students. However, in the experiential learning group (Wet lab group), the gain of knowledge was higher compared to that in the traditional group (lecture group).
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Visual rehabilitation of people with oculocutaneous albinism in a tertiary clinical setting in Pakistan p. 111
Mufarriq Shah, Muhammad T Khan, Nasir Saeed
DOI:10.4103/1319-4534.305036  
PURPOSE: All people with oculocutaneous albinism (OCA) have reduced vision. This study aimed to assess the benefits of low vision aids for people with OCA. METHODS: Seventy-seven consecutive people with OCA age 4 years and above examined in a low vision clinic were included in the study. Uncorrected and best-corrected visual acuity (VA), VA with low vision devices, types of low vision aids, and refractive errors data were analyzed. RESULTS: Of the 77 people with OCA, 57% were in the age group between 4 and 15 years and 43% in the age group of 16 years and above. At the time of presentation, the percentages of visually impaired, severe visually impaired, and blind (using WHO low vision criteria) were 52%, 22%, and 25%. Among them, 39% has near VA of 1 M or better. Difference in the means of the spherical equivalent refractive error in the right eyes and left eyes was -0.494 diopters (-01.686, 0.699; 95% confidence interval). VA improved significantly after adequate refractive correction by more than one log MAR lines in 38.6% (P < 0.01). With low vision devices, in 85.7% (n = 66) participants, VA was enhanced to normal level (6/18 or better) in the better eye while 7.8% still remained in the blind category. Telescopes were prescribed to 61% people for the enhancement of distance VA and hand hold magnifiers were prescribed to 22% people to meet their needs. CONCLUSION: Low vision aids can be successfully used in visual rehabilitation of people with OCA to meet their needs.
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Prevalence of laser refractive surgery among ophthalmologists in Saudi Arabia p. 116
Nasser Alsabaani, Mohammed S Alshehri, Mohammed A AlFlan, Nabil J Awadalla
DOI:10.4103/1319-4534.305043  
PURPOSE: The primary aims of this study are to assess the prevalence of excimer laser refractive surgery among ophthalmologists in Saudi Arabia, evaluates the satisfaction rates among ophthalmologists who have undergone laser refractive surgery and whether they would recommend the procedure to their immediate family members. METHODS: A cross-sectional study surveyed ophthalmologist irrespective of specialty or subspecialty in Saudi Arabia. A self-reported survey tool has been used for data collection. Candidates were contacted by email and WhatsApp messages that introduced the nature of the study and an online link to a survey was included. For those who did not respond to the digital contact, direct survey interviews were conducted at an Ophthalmology conference in Riyadh, Saudi Arabia, 2018. RESULTS: The final study sample was comprised of 183 ophthalmologists. Most of them 107 (58%) reported that they currently are performing laser refractive surgery.There were 73 (39.89%) ophthalmologist who self-reported that they are emmetropic, 110 (60.11%) self-reported themselves as ametropic, not including presbyopia.Of the 110 ophthalmologists with refractive errors, 52 (47.27%) were candidate for laser refractive surgery for myopia, hyperopia or astigmatism. Most of non- candidates attributed the non-candidacy to non- specific reasons and dry eye. Of the 52 participants who reported themselves as candidates for laser refractive surgery, 20 (38.46%) reported that they had undergone laser refractive surgery, and 32 (61.54%) had not. Most of them (50%) reported that they “like to wear glasses or contact lenses. In general, 14 (70%) reported complete satisfaction with the postoperative outcome.Of all ophthalmologists participated in the study, 94% would advise laser refractive surgery to their first-degree relatives. CONCLUSION: Excimer laser vision correction among ophthalmologists in Saudi is much higher than the market penetration in the general population reported in other countries. Most of the ophthalmologists who underwent the procedure were satisfied with the outcome.
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The association between personality traits and dry eye disease: A cross-sectional study p. 120
Kaberi B. Feroze, Zahrah A. M. AlAbdullah, Arwa H.A. AlOnayzan, Abdulwahab Pattath
DOI:10.4103/1319-4534.305020  
PURPOSE: Dry eye disease (DED) is a growing public health concern that causes significant visual disability and interferes with the quality of life. The aim of the study is to analyze the relationship between personality traits and DED symptoms in the eastern region of Saudi Arabia. METHODS: A cross-sectional study was carried out in the Eastern Province of Saudi Arabia in 2018. A total of 613 subjects participated in this study. Ocular surface disease index was first distributed online to assess the subjective symptoms of DED. Then, persons with DED were selectively chosen to be tested by the Big Personality Trait Inventory questionnaire. Data were analyzed using one-way ANOVA test at a level of significance, P < 0.05. RESULTS: 57.7% of the patients reported symptoms of DED. There was a significant positive correlation between DED and neuroticism personality trait. DED severity was found to be significantly correlated in persons with chronic diseases. CONCLUSION: This study suggests that psychological problems have an impact on DEDs in a way that needed to be studied.
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REVIEW ARTICLE Top

Evaluation and management consideration for children who are visually impaired p. 124
Khadija S Shahid, Mark E Wilkinson
DOI:10.4103/1319-4534.305048  
Clinical low vision evaluations provided by optometrists or ophthalmologists trained and experienced in low vision rehabilitation care should be recommended for all children with a visual impairment, regardless of the cause of their vision loss, their age or the severity of their additional disabilities. This article discusses an effective model for pediatric vision rehabilitation service.
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CASE REPORTS Top

Retained intracameral cotton fibers following phaco-vitrectomy p. 129
Christina Y Weng, Weijie V Lin, Joseph F Morales
DOI:10.4103/1319-4534.305038  
This report describes a 76-year-old female who presented with cotton fibers retained in the anterior chamber following a combined phaco-vitrectomy. These fibers did not cause any complications in her postoperative course. This observation has not been previously reported in association with a combined anterior segment-posterior segment surgery. Retained cotton fibers are typically inert and do not require intervention. However, this iatrogenic postoperative complication should be avoided if possible, and several approaches for how to do so are discussed.
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Traumatic total iridectomy with “pseudo-iris” p. 131
Carlos Rocha-de-Lossada, Rodriguez-Calvo-de-Mora Marina, Rachwani Rahul, Borroni Davide, Santos O. Álvaro, Hernando-Ayala Carlos
DOI:10.4103/1319-4534.305047  
Blunt trauma may cause a wound in the site of the cataract incision in patients that have received this surgery, even decades after the procedure. The opening of the incision seems to avoid globe rupture, acting as a “liberating valve” We report a case of a 92-year-old woman with advanced dry macular degeneration who is referred to our department after suffering a blunt trauma in her left eye with a nightstand. She was diagnosed of a traumatic total iridectomy due to iris extrusion through a 2.75 mm cataract incision after injury and vitreous hemorrhage, sparing an intact intraocular lens and capsular bag, as well as peripheral remnants of cortical material in the capsular bag and anterior capsule opacity resembling ”pseudoiris“. After the vitreous hemorrhage was completely resolved she referred no photophobia. Consequently, although a bad visual acuity of the patient could mitigate patient's photophobia, we believed that her ”pseudoiris” plays an important role in diminishing the possible symptoms of photophobia.
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Isolated traumatic optic nerve avulsion in a boy who suffered a horse kick p. 134
Huda Al-Ghadeer, Mohammed Al-Amry, Sahar M Elkhamary, Arif O Khan
DOI:10.4103/1319-4534.305045  
We report a case with traumatic avulsion of optic nerve caused by a horse kick in a child that caused loss of vision. Optic nerve avulsion is a rare injury usually associated with maxillofacial structures. Our patient had no light perception in the left eye. The left pupil was dilated and unreactive to light. The left globe was intact. A non-contrast axial computed tomography scan of the orbit demonstrated a widened and altered nerve globe junction with periorbital soft tissue edema. At six month following the injury, subsequent magnetic resonance imaging of the orbit showed that the preseptal soft tissue thickening dispersed spontaneously with total avulsion of the optic nerve and variable severity of surrounding hemorrhage. The patient did not develop phthisis bulbi during three years of follow up. Traumatic optic nerve avulsion presents with a dramatic clinical picture, and can lead to the development of severe visual loss.
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Adult presentation of retinoblastoma in Saudi patient p. 136
Saba Al Rashaed, Sahar M. Elkhamary, Osama Al Sheikh, Saleh Al Mesfer, Hassan Al-Dhibi, Azza Al Maktabi
DOI:10.4103/1319-4534.305046  
To describe an unusual case of retinoblastoma in adult Saudi. A 21-year-old Saudi male developed acute unilateral visual loss due to a large intraocular lesion in his left eye. Within five days of presentation, the tumor enlarged rapidly causing angle closure glaucoma and orbital cellulitis like picture. The patient underwent enucleation and the histopathology specimen confirmed the presence of an undifferentiated type tumor cell that was consistent with retinoblastoma with choroidal and optic nerve invasion. Retinoblastoma should be considered in the differential diagnosis of an intraocular mass in adults. To the best of our knowledge, this is the first reported case of an adult presentation of retinoblastoma in Saudi patient.
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Favourable outcome in retinal macrovessel-related choroidal neovascularization p. 139
Waseem M Al-Zamil, Moustafa S Magliyah
DOI:10.4103/1319-4534.305037  
Congenital retinal macrovessel (CRM) is an aberrant retinal blood vessel, which crosses the central macula and has tributaries extending on both sides of the horizontal raphe. It is a rare vascular condition, usually asymptomatic and incidentally discovered on routine fundus exam. This report describes a case of venous CRM associated with visual impairment secondary to choroidal nonvascular membrane (CNV). Treatment with intravitreal injection of aflibercept resulted in a favourable visual as well as anatomical outcome.
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Posterior segment optical coherence tomography findings in a case of nephropathic cystinosis p. 142
Omar Al Abdulsalam
DOI:10.4103/1319-4534.305049  
Cystinosis is a rare autosomal recessive lysosomal storage disorder characterized by abnormal accumulation of intracellular cystine in various tissues including the brain, kidneys, bones, and eyes. Infantile nephropathic cystinosis is the most severe phenotype of cystinosis that has been associated with a wide spectrum of ocular features. In this report, the author describes a posterior segment spectral-domain optical coherence tomography (SD-OCT) finding that has not been previously reported in a case of nephropathic cystinosis.
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Surgical removal of inadvertent intralenticular sustained-release dexamethasone implant (ozurdex) and implant one-piece posterior capsule intraocular lens p. 145
Abdulrahman Albuainain, Mohanna Al Jindan, Bedoor Al Bloushi
DOI:10.4103/1319-4534.305044  
To report the therapeutic efficacy and results of an accidentally injected intralenticular sustained-release dexamethasone implant (Ozurdex) in a patient with macular edema secondary to diabetic macular edema.Dexamethasone intravitreal implant is an approved formulation in the management of macular edema. The most common adversarial effects are an elevation of intraocular pressure (IOP) and cataract, but the unintentional injection of the dexamethasone implant into the lens is a particularly rare event.We report a case of a 72-year-old man treated for resistant Diabetic macular edema (DME) with dexamethasone intravitreal implant (Ozurdex, Allergan, Inc., Irvine, CA, USA) in which the technique was complicated by accidental implantation into the lens body and review the management. The patient underwent phacoemulsification of the lens, removal of the Ozurdex, intravitreal Avastin injection, and implant of a one-piece lens in the posterior capsule.
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Central retinal vein occlusion associated with the use of tranexamic acid p. 148
Ali M Al Shaharani, Turki A Al Ghamdi
DOI:10.4103/1319-4534.305039  
Here we report a case of central retinal vein occlusion that developed after using tranexamic acid. A 46-year-old female not known to have any previous illness came to the ophthalmology clinic complaining of sudden blurring of the vision in her left eye for almost 1 month, for which it is advised that tranexamic acid should be discontinued.
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