Diabetic retinopathy (DR) is a complication of diabetes mellitus that can cause blindness. As the prevalence of diabetes increases globally and patients live longer, the cases of DR are increasing. To address the visual disabilities due to DR, screening of all diabetics is suggested for early detection. The rationale and principles of DR screening are discussed. Based on the available evidence, the magnitude of DR in countries in the Eastern Mediterranean region (EMR) is presented. Public health strategies to control visual disabilities due to DR are discussed. These include generating evidence for planning, implementing standard operating procedures, periodic DR screening, focusing on primary prevention of DR, strengthening DR management, health information management and retrieval systems for DR, rehabilitating DR visually disabled, using low-cost technologies, adopting a comprehensive approach by integrating DR care into the existing health systems, health promotion/counseling, and involving the community. Although adopting the public health approach for DR has been accepted as a priority by member countries of EMR, challenges in implementation remain. These include limitations in the public health approach for DR compared to that for cataract, few skilled workers, poor health systems and lack of motivation in affecting health-related lifestyle changes in diabetics.Visual disabilities due to DR are likely to increase in the coming years. An organized public health approach must be adopted and all stakeholders must work together to control severe visual disabilities due to DR.

Purpose: To investigate the efficacy of photodynamic therapy (PDT) with verteporfin for the treatment of patients with corneal neovascularization. Materials and Methods: Retrospective interventional case series of 33 eyes of 32 patients with stable corneal neovascularization who were refractory to conventional treatment and were treated with single photodynamic therapy with verteporfin (6 mg/m ^[2] ) at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia between January 1, 2007 and December 30, 2009. The mean age was 40.7 ± 19 years (range 16-76 years). The mean follow-up for all patients was 13.1 ± 5.5 months (range 6-24 months). The average amount of corneal neovascularization was 2.7 ± 1.9 (1-10). Corneal neovascularization was deep in 19 (57.6%) eyes and superficial in 14 (42.4%) eyes. Preoperative and postoperative visual acuity and intraocular pressure, and clinical outcome of the treatment were assessed. Statistical analysis was performed to investigate the association to potential risk factors, to assess the change in data and determine the risks for failure. A P-value less than 0.05 was statistically significant. Results: At the last follow-up visit, 22 (66.7%) eyes showed a decrease in corneal neovascularization and evidence of vascular thrombosis. Complete vascular occlusion was achieved in 14 (42.4%) eyes, partial occlusion was achieved in 8 (24.2%) eyes, and the vessels were patent in 11 (33.3%) eyes. The corneal neovascularization score and depth of the vessels were found to be significant risk factors for failure (P = 0.0001 and 0.046, respectively). However, the diagnoses or causes of corneal neovascularisation were not statistically significant. No significant systemic or ocular complications associated with photodynamic therapy were observed. Conclusion: Photodynamic therapy with verteporfin was effective for the treatment of corneal neovascularization in the majority of the cases in this study.

Purpose: To determine the prevalence of xerophthalmia at a traditional boarding school where children do not receive a diet adequate in vitamin A. Materials and Methods: A cross-sectional survey of 406 males residing in a Quranic traditional school was conducted using the World Health Organization xerophthalmia checklist. The association between the prevalence of night blindness and proportion of students staying at the school for 6 consecutive months and those eating solely at the school was investigated. The difference in age between children with night blindness and those without was investigated. Statistical significance was indicated by P<0.05. Results: The prevalence of night blindness, conjunctival xerosis and Bitot's spots was 24%, 12.5% and 1%, respectively. None of the boys had corneal ulceration, corneal scars and corneal xerosis. No significant association was observed between the differences in mean age and development of night blindness (P=0.657). There was a significant association between the duration of stay (cut-off of 6 months continuously) at the institute and the development of night blindness (P=0.023). There was no statistical significance between regularly eating at the "maseed" and outside the "maseed" and the development of night blindness (P=0.75). Conclusion: Children residing at a traditional school are vulnerable to developing xerophthalmia where the diet is inadequate in vitamin A. Institutional caregivers should be made aware of the importance of providing a balanced diet rich in vitamin A. Institutional caregivers should also be educated on the signs and symptoms of vitamin A deficiency for early detection of xerophthalmia.

Purpose: To compare central corneal thickness (CCT) in subjects with controlled primary congenital glaucoma (PCG) and nonglaucomatous subjects and to investigate the correlation between CCT and intraocular pressure (IOP) in the study population. Materials and Methods: Twenty-three consecutive PCG cases with controlled IOP and no clinical evidence of corneal edema comprised the Study Group. There was an interval of at least 2 months between last intraocular surgery and inclusion in the study. Twenty-one subjects with strabismus or lacrimal drainage insufficiency who did not have glaucoma or any history of intraocular surgery or ocular trauma comprised the control group. The Control Group was age and sex-matched. Data from ultrasonic pachymetry and applanation tonometry were analyzed for differences between groups. Correlation of the study parameters was investigated. A P-value less than 0.05 was statistically significant. Results: Data from both eyes of subjects in the Study Group and Control Group were included in the original analysis. Mean CCT was statistically significantly higher in the Study Group compared to the Control Group (589.42 ± 53.44 μm vs. 556.14 ± 30.51 μm, respectively; P=0.001). There was a significant correlation between CCT and IOP (r=0.63; P<0.0001). Similar statistically significant outcomes were observed when only one eye per subject was used in a reanalysis of the data for the Study and Control Groups. Conclusion: Patients with PCG who had controlled IOP have statistically significantly thicker corneas than nonglaucomatous age and sex-matched subjects The thicker cornea could significantly alter IOP measurement with applanation tonometry. Pachymetry should be considered an essential part of the evaluation for PCG.

Purpose: To evaluate the clinical features, and visual outcomes of sterile uveitis after iris-fixated phakic intraocular lens implantation (pIOLs) (Artisan-Artiflex^® and Verisyse-Veriflex^® ). Material and Methods: In this retrospective non-comparative case series, the medical records of 117 eyes implanted with Artisan-Artiflex^® (Ophtec BV, Groningen, Netherlands) and Verisyse-Veriflex^® (AMO, Santa Ana, CA) iris claw phakic IOLs were analyzed for postimplantation sterile uveitis. The mean age of the 87 patients included in the study was 27.2±7.4 years. Of these patients, 56 (64.3%) were men and 31 (35.6%) were women. Patient age, gender, IOL brand type, refractive error, optic diameter, unilateral vs bilateral implantation, and anterior chamber depth were analyzed. Features of uveitis, uncorrected and best corrected visual acuity (VA) at presentation and at follow-up visits were examined. The mean follow-up time was 14.6 months (range: 6-37 months). Results: Clinically significant uveitis was observed in 12 of 117 eyes (10.3%) in a total of ten patients. Of these ten patients, four (40%) were women and six (60%) were men, and the mean age was 25.1±5.3 years (range: 18-36 years). Among those with bilateral implantation, 6.9% of patients developed bilateral uveitis, while 13.8% (4 of the 29 implanted bilaterally) developed unilateral uveitis. Foldable pIOL implantation was the only variable associated with the development of uveitis (P=.03). Conclusion: Although the prognosis is usually benign, sterile uveitis occurred in 10.3% of patients after iris-fixated pIOL implantation. The implantation of a foldable pIOL was the only variable associated with sterile uveitis. Appropriate medical management can be effective treatment, without the need for pIOL replacement.

Purpose: Previous studies have evaluated macular retinal thickness (RT) and nerve fiber layer thickness (RNFLT) changes in early glaucoma using elaborate optical coherence tomography (OCT) scanning protocols. Materials and Methods: This study examines RT and RNFLT using standard scanning protocols in early glaucoma. In this prospective, nonrandomized case series, 95 eyes of 95 patients were evaluated, including 29 nonglaucomatous subjects (control group), 34 glaucoma suspects, and 32 early manifest glaucoma patients. RT and RNFLT were measured using scanning fast macular thickness map and Fast RNFLT (3.4) protocols on a 1.70 mm radius around the macular center (respectively) in all four quadrants. The fast RNFLT (3.4) protocol was transposed on the macula from the peri-papillary area. Data were statistically analyzed for differences between groups, and for correlations between parameters. P<0.5 was statistically significant. Results: Both early manifest glaucoma patients and glaucoma suspects had significantly lower RT than controls in all quadrants. RNFLT differences in all quadrants were not statistically significant (P>0.05). RT was significantly inversely correlated with axial length in early manifest glaucoma patients and glaucoma suspects but not in controls. Conclusions: The finding that RT was significantly lower in early manifest glaucoma patients and glaucoma suspects indicates that the transposition of the OCT fast RNFL thickness (3.4) protocol from the peri-papillary area to the peri-macular area can be used for early glaucoma diagnosis. Intraretinal changes in early glaucoma, likely precede nerve fiber changes.

Purpose: We compared Humphrey Matrix FDT 30-2 (FDT) and Humphrey Visual Field Analyzer 30-2 SITA standard (SAP) in the assessment of anterior (optic nerve or chiasm) and posterior (retro-chiasmal) afferent visual pathway defects. Materials and Methods: In this retrospective comparative study, the charts of 37 patients (16 males, range 13-84 years, mean 72.1), with neuro-ophthalmic visual field defects who were tested with both FDT and SAP, were reviewed. Two masked graders assessed the concordance and extent of field defects between the perimeters. The mean concordance between anterior and posterior disease was compared using the Wilcoxon rank sum test. The mean deviation (MD) and pattern standard deviation (PSD) of each perimeter were correlated with the Spearman coefficient. Results: Twenty-eight patients had anterior and nine had posterior disease. Most had a fair or good concordance (89.3% anterior, 88.9% posterior). When comparing anterior to posterior disease, the mean concordance of the defects of the two parameters was not statistically different (P = 0.94 and P = 0.61 for total deviation and pattern deviation, respectively). The MD and PSD between perimeters had a significant correlation. Conclusions: Our series, using 30-2 field analysis, demonstrates fair to good correlation between FDT and SAP in the majority of patients. In roughly 10% findings between FDT and SAP were discordant. This difference was similar for anterior and posterior disease.

Purpose: The purpose of this study was to assess the results of bleb needling in glaucomatous patients with late failed filtering blebs. Materials and Methods: A retrospective case series of 27 eyes of 27 patients was considered. All patients underwent needle bleb revision with adjuvant mitomycin-C performed at the slit lamp, during an office visit. Complete success was defined as postneedling intraocular pressure (IOP) ≤ 21 mmHg without any antiglaucoma medications and qualified success was IOP ≤ 21 mmHg with topical antiglaucoma medications. Results: There were 12 eyes with encapsulated blebs and 15 eyes with flat blebs. The mean interval between index filtering surgery and bleb revision was 32.74 ± 15.36 months. Mean IOP was 25.07 ± 4.80 mmHg before surgery and 19.66 ± 4.97 mmHg at last postoperative follow-up. The mean follow-up was 20.31 ± 15.63 months. Complete and qualified successes were 7.4% and 51.9%, respectively. Cumulative rates of success at 1, 2, 3, and 4 years were 76%, 65%, 49%, and 37%, respectively. The mean number of antiglaucoma medications was reduced from 3.15 ± 0.36 preoperatively to 2.33 ± 1.21 postoperatively (P<0.001). Conclusion: Slit-lamp needle revision in office is a simple and effective method for treating late encapsulated or flat filtering blebs without significant complications even for late bleb failure.

Purpose: To evaluate the astigmatic correcting effect of paired opposite clear corneal incisions (OCCIs) on the steep axis in patients with residual astigmatism after laser in situ keratomileusis (LASIK) Materials and Methods: Thirty-one eyes of 24 patients with a mean age of 28.4 years ±2.46 (range, 19-36 years) were recruited for the study. Inclusion criteria included residual astigmatism of ≥1.5 diopter (D) after LASIK with inadequate residual stromal bed thickness that precluded ablation. The cohort was divided into two groups; group I (with astigmatism ranging from -1.5 D to -2.5 D) and group II (with astigmatism > -2.5 D). The steep axis was marked prior to surgery. Paired three-step self-sealing opposite clear corneal incisions were performed 1-mm anterior to the limbus on the steep axis with 3.2-mm keratome for group I and 4.1 mm for group II. Patients were examined 1 day, 1 week, 1 month, 3 months and 6 months, postoperatively. Visual acuity, refraction, keratometry, and corneal topography were evaluated preoperatively and postoperatively. Analysis of the difference between groups was performed with the Student t-test. P<0.05 was considered statistically significant. Results: The mean uncorrected visual acuity (UCVA) improved from 0.35±0.13 (range, 0.1-0.6) to 0.78±0.19 (range, 0.5-1) in group I and from 0.26±0.19 (range, 0.1-0.5) to 0.7±0.18 (range, 0.4-1) in group II. The increase in UCVA was statistically significant in both groups (P=0.001, both cases). The mean preoperative and postoperative keratometric astigmatism in group I was 2.0±0.48 D (range, 1.5-2.5 D) and 0.8±0.37 D (range, 0.1-1.4 D), respectively. The decrease in keratometric astigmatism was highly statistically significant in group II (P=0.001.). Mean surgically induced astigmatic reduction by vector analysis was 1.47±0.85 D and 2.21±0.97 D in groups I and II respectively. There were no incision-related complications. Conclusions: Paired OCCIs were predictable and effective in correcting post-LASIK astigmatism and required no extra surgical skill or expensive instruments. OCCIs are especially useful in eyes with insufficient corneal thickness for LASIK retreatment.

Purpose: To use spectral domain optical coherence tomography (OCT) to assess the features of the inner and outer layers of the macula in subjects with retinitis pigmentosa (RP). Design: Prospective observational comparative study. Materials and Methods: Subjects with RP with reduced central visual acuity and central macular thinning (RP group) underwent spectral domain OCT evaluation along with age-matched healthy control subjects (control group). Using the E-MM5 raster protocol, a 5 × 5 mm central macular cut was acquired with inner and outer macular volumes serving as the primary outcome measures. A structural analysis of the inner and outer retinal layers at the macula in the RP group was also performed using the HD cross-line protocol. Results: The RP group comprised six eyes of six RP subjects and control group comprised six eyes of six control subjects. The outer macular volume was significantly lower (P<0.05) in the RP group (2.01±0.44 mm ^[3] ) compared to the control group (4.68±0.16 mm ^[3] ). There was no difference in the mean inner macular volume between the RP group (2.46±0.24 mm ^[3] ) and the control group (2.55±0.22 mm ^[3] ). No significant structural alteration was noted in the inner retinal layers of the RP group. There was no significant correlation (r = -0.04, P>0.05) between best-corrected visual acuity and outer macular volume in the RP group. Conclusions: Spectral domain OCT findings confirm that RP preferentially affects the outer retinal layers in the macula. Although the number of patients included in this study was small, it demonstrated relatively well-preserved volume and morphology of the inner retinal layers using spectral domain OCT.

Purpose:To study the clinical profile of pseudoexfoliation (PEX) syndrome in a hospital setting. Materials and Methods: A case series of patients with PEX, with and without glaucoma attending the general ophthalmology clinic of a tertiary care center in South India. All patients underwent a complete ophthalmologic evaluation including recording diurnal variation of tension (DVT), gonioscopy and visual field assessment. Results: The study cohort comprised 529 patients (752 eyes). There were 296 (56%) females. The highest number of patients (261 patients) was from the age group between 60 and 69 years. Of 752 eyes, 57.8% eyes had unilateral PEX and 72% had established PEX. Gonioscopy showed open angles in 98.1% of eyes. Intraocular pressure (IOP) greater than 21 mmHg in at least 1 of 4 measurements was recorded in 5.7% eyes. DVT was normal in 96.4% of unilateral PEX eyes, similar to fellow non-PEX eyes. Pseudoexfoliation glaucoma occurred in 1.9% of eyes and 4.7% of eyes were glaucoma suspects. There was no correlation between the stage of PEX and increased IOP. Mean central corneal thickness of PEX eyes was 522 ± 27μ. Pupillary dilatation in 90.5% eyes with early PEX was ≥ 7 mm. Conclusions: A small percentage of PEX eyes had raised IOP, and the number of eyes with glaucomatous optic neuropathy was even lower. PEX eyes did not demonstrate wide fluctuations in IOP. No correlation was found between raised IOP and stage of PEX. There was good pupillary dilatation in early stage PEX eyes suggesting that all PEX eyes may not have poor pupillary dilatation and related complications.

Although pupil-sparing in acute unilateral complete third nerve palsy is often a sign of ischemic nerve injury, it is not specific for injury outside of the midbrain. This report documents acute pupil-sparing complete third nerve palsy in an otherwise healthy young adult with patent foramen ovale and associated atrial dilatation who suffered cryptogenic focal midbrain stroke, presumably from a paradoxical embolism. The patent foramen ovale was surgically closed. Over the next several months neurological recovery was complete except for diplopia and relatively comitant hypotropia, which responded well to conventional strabismus surgery.

We herein report a case with multifocal cysticercosis - sub-conjunctival cysticercus cyst, sub-retinal cysticercosis, and neurocysticercosis in a child. The optical coherence tomography (OCT) findings of the sub-retinal cysticercus cyst are reported. He was treated with anti-helminthic drugs and oral prednisolone followed by surgical removal of the sub-retinal cyst. He subsequently underwent silicone oil removal with lens aspiration and intraocular lens implantation maintaining stable vision

We report a case of cat-scratch disease with unusual posterior segment manifestations. A 12-year-old healthy male presented with three weeks history of decreased visual acuity in the right eye. A significant history of cat exposure and elevated Bartonella titers were present. A large white-gray vascularized mass extending off the optic disk, an early stellate maculopathy, a plaque of choroiditis, an inferior serous retinal detachment involving the macula were present in the right eye. Sector papillitis and a focal area of chorioretinitis along the superotemporal arcade with associated retinal artery to vein anastomosis were present in the left eye. Bilateral optic nerve head involvement including peripapillary angiomatosis, retinal-retinal anastomosis and plaque choroiditis as ocular complications of cat-scratch disease have not been previously described to our knowledge and make this case noteworthy.

This case describes a patient with chronic central retinal artery occlusion in one eye and end-stage traumatic glaucoma in the fellow eye. Optical coherence tomography (OCT) of the macula of the chronic phase of central retinal artery occlusion of the right eye indicated loss of the normal foveal depression, extensive inner retinal atrophy, and marked retinal thinning. In contrast, scans of the left eye with end-stage glaucoma demonstrated an intact foveal depression and limited retinal thinning. The pattern of macular OCT findings in this patient illustrates distinguishing features between chronic central retinal artery occlusion and chronic optic neuropathy due to end-stage glaucoma.

A 21-year-old female presented with progressive bilateral visual loss for the past 8 years. The patient had no history of systemic disease, surgery or medications. Complete ophthalmologic examination and topography were performed. On ophthalmic examination, uncorrected visual acuity was counting fingers at 2.5 m (20/50 with pinhole) in the right and left eyes. Both corneas appeared hazy on gross examination. On slit-lamp biomicroscopy, focal grayish-white opacities with indistinct borders were noted in the superficial and deep corneal stroma of both eyes. Both corneas were thin and bulging. Corneal topography showed a pattern consistent with keratoconus. The patient underwent penetrating keratoplasty (PKP). Histopathologic studies after PKP confirmed the diagnosis of macular corneal dystrophy and keratoconus in the same eye. The patient was clinically diagnosed as a case of concurrent macular dystrophy and keratoconus, which is a very rare presentation.

A case report of a 68-year-old male who developed acute retinal necrosis (ARN) after Boston type I keratoprosthesis is presented. The procedure was performed for multiple graft failure secondary to herpetic keratitis. Clinical data including visual acuity, color fundus photography, fluorescein angiography, laboratory tests findings, and management are presented. After exclusion of other causes by laboratory workup, the patient was diagnosed with ARN most likely secondary to herpetic infection. Intravenous acyclovir and oral prednisolone were administered to the patient resulting in marked improvement in visual acuity and regression in the size of the retinitis. The patient eventually developed a soft eye and choroidal detachment with light perception vision. In patients with a history of herpetic keratitis or keratouveitis, it is highly advisable to maintain prophylactic systemic antiviral treatment before and after any ocular procedure such as the Boston keratoprosthesis.

Rhino-orbito-cerebral mucormycosis is a fungal infection that can be fatal especially in immunocompromised patients. It is extremely rare in immunocompetent individuals. We describe here an immunocompetent patient who survived rhino-orbito-cerebral mucormycosis due to Saksenaea vasiformis, and provide a literature review of this rare entity.

A 16-year-old woman presented with Marfan syndrome and bilateral ectopia lentis. The surgical treatment including removal of the crystalline lens and implantation of an iris-supported intraocular lens in both eyes at a week interval. Postoperatively, the biomicroscopic examination showed total pupil closure bilaterally. After the topical tropicamide treatment, the pupil returned to normal shape.

We present a report of a 28-year-old female with fungal keratitis due to Acremonium that was unresponsive to full medical therapy over 3 weeks. The patient was treated with superficial keratectomy, intrastromal and intracameral voriconazole injections. There was a marked clinical improvement beginning on day 3 post-therapy that was sustained until the last follow-up at 6 months. This is the first case of fungal keratitis due to Acremonium treated by a combination of intrastromal and intracameral voriconazole. This cost-effective treatment modality proved to be significant in impeding the progression of this potentially blinding disease and improving visual prognosis.