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                 SUNDAY, MARCH 4                                          Duane Retraction Syndrome at the KKESH

  Session S1A – Pediatric Ophthalmology                                   Arif O. Khan, Darren T Oystreck

                                                                          Purpose: To describe clinical features of patients referred to
Slipped and Lost Muscles                                                  the King Khaled Eye Specialist Hospital (KKESH) with
                                                                          Duane retraction syndrome (DRS).
                                                                          Methods: Retrospective chart review KKESH patients (1982
Anthony Murray
                                                                          to 2003) with the diagnosis of DRS. Patients with prior
                                                                          strabismus surgery were excluded.
The slipped rectus muscle and the lost rectus muscle are
                                                                          Results: Of 404 DRS patients, 347(86%) were unilateral,
recognised complications of strabismus surgery and retinal
                                                                          57(14%) were bilateral, and 111(27%) had amblyopia.
surgery and may also result from trauma. The tendon of the
                                                                          There were 221(55%) females and 182(45%) males. Huber
slipped muscle may break away from its scleral attachment
                                                                          classification was as follows:
and recoil within its capsule towards its penetration within
                                                                          315(78%) Type I, 16(4%) Type II, and 77(19%) Type III.
Tenon’s capsule. Although weakened, the slipped horizontal
                                                                          Of the 57 bilateral cases, 25 (44%) were female and 32 (56%)
or vertical muscle continues to deliver some degree of duction
                                                                          were male.
up to and past the midline. Unlike the slipped muscle within
                                                                          Discussion: Overall clinical features of KKESH DRS
its capsule, the disinserted or severed muscle usually attaches
                                                                          patients are similar to those reported in series throughout
to the sclera at an exaggerated recession site, providing some
                                                                          the world. However, our referred bilateral DRS patients are
degree of limited duction in its field of action. The lost
                                                                          more commonly male. Further studies are required to
muscle , on the other hand, recoils through Tenon’s capsule
                                                                          determine whether this is a worldwide trend.
back into the posterior orbit and delivers little or no surgical
duction when stimulated. The surgical findings,
management and prognosis differ for each of these
complications.                                                            Strabismus as a Masquerade
An approach to the prevention and management of these
problems will be presented.                                               David Taylor

                                                                          A1) Symptoms
Congenital Fibrosis of the Extra-Ocular Muscles:                              1. Headache
                                                                              2. Facial spasms
An Update
                                                                              3. Subtle Vision disorders
                                                                              4. Double vision
Darren T. Oystreck
                                                                          B) Signs
                                                                              1. Color vision changed, asymmetrical or !ì in a girl
Background: The understanding of Congenital Fibrosis of
                                                                              2. Deteriorating Acuity
the Extra-Ocular muscles (CFEOM) has improved
                                                                              3. Or-Amblyopia that doesn’t improve with occlusion
significantly in the past few years in part by the collaboration
                                                                              4. New Nystagmus
of several international investigators.
                                                                              5. Unexplained head turns or tilts
Purpose: To highlight the important work done at KKESH
                                                                              6. Beware the uncooperative child!
as part of this team. Outline the newly devised concepts
                                                                              7. Visual fields
underlying the pathophysiology of CFEOM that arose from
                                                                              8. Electrophysiology
this work. To summarize the most recent updates involving
                                                                              9. Anorexia in a boy or with weak corrected vision
genetically defined variants of CFEOM and its phenotypic
                                                                          C) The Nature and History of the Strabismus
                                                                              1. Signs of nerve paresis
Methods: To review the results of past and on-going studies
                                                                              2. ‘A’ Eso
done at KKESH.
                                                                              3. D>N Eso (unoperated)
Conclusions: Integration between genetics and clinical data
                                                                              4. Early onset Exotropia
has increased significantly for various forms of congenital
                                                                              5. No FH
eye movement disorders. This presentation discusses one
                                                                              6. No Refractive error
such condition.
                                                                              7. Sudden onset strabismus

                                     Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                63
     Saudi Ophthalmology 2007
        8. Unusual progression                                                Conclusion: The outcome of Mooren’s ulcer was poor despite
        9. Any other signs or symptoms                                        immunosuppressive and surgical treatment. New approaches
        10. Varying signs                                                     for treatment are highly desirable.
     D) “Axioms”
        1. Always be the third Doctor!
        2. Listen to the referrer                                             Corneoscleral Grafts: Indications, Techniques and
        3. Listen to the child & parents                                      Outcomes
        4. Suspect “Hysterical” symptoms
        5. Record “negative” findings                                         Richard Forster
        6. There has to be a reason
                                                                              This is a summary of 12 corneoscleral grafts indicated by 3
                                                                              post cataract anterior chamber cysts, 3 cases of epithelial
                                                                              ingrowth, 3 cases of infections of scleral keratitis, and 3 cases
      Session S1B – Cataract and Refractive Surgery                           of invasive squamous cell carcinoma. Technique, visual
                                                                              outcomes and potential complications will be discussed.

     Long-term Outcome of Mooren’s Ulcer in Saudi Arabia
                                                                              Penetrating Keratoplasty in Peter’s Anomaly at KKESH
     Anoud Saati, Ali Al-Rajhi, and Khaled Tabbara
                                                                              Ali A. Al-Rajhi, Ali Al-Ghamdi and Michael Wagoner
     Purpose: The purpose of this study was to evaluate the
     clinical manifestations and long-term outcome of Mooren’s                Purpose:To review the graft survival outcome of Penetrating
     ulcer and to assess the associated risk factors.                         Keratoplasty (PKP) in Peter’s anomaly.
     Methods: The medical records of 44 patients with Mooren’s                Methods: A total of 29 eyes of 21 patients (8 M, 13 F) that
     ulcer were reviewed. The diagnosis was based on the clinical             underwent PKP at King Khaled Eye Specialist Hospital
     manifestations and absence of systemic diseases. Patients who            (KKESH) were studied retrospectively. The mean age at
     had a follow-up period of less than 6 months were excluded.              surgery was 12 months (range, 1-96 months). Eighteen cases
     Data included history, ophthalmic findings, natural course               had preoperative glaucoma procedures and one had globe
     of the disease, complications and outcome after topical,                 rupture repair and 16 simultaneous surgical procedures (10
     systemic medications, and surgical treatment.                            glaucoma procedures).
     Results: There were a total of 70 eyes among 44 patients (37             Results:The overall graft survival at last follow-up visit was
     males and 7 female). The mean age was 65.5 years range (14-              24% (7 cases). Sixty three percent (14 cases) and 82% (18
     98). The incidence of Mooren’s ulcer in the outpatient clinic            cases) of grafts failed in the first one and two years
     was 4.4 in 10,000. There were 26 cases with bilateral disease            respectively. Complications (24/29) included loose sutures
     and 18 cases with unilateral disease. None of the 19 patients            (9), raised IOP (9), vascularization (9), microbial keratitis
     who were tested for Hepatitis C antibodies were positive. Two            (6), graft rejection (3), retinal detachment (2),
     out of 12 patients that had stool analysis had parasitic                 endophthalmitis (1), and cataract (1). Although only 17%
     infestations. Management included: perilimbal conjunctival               (4 grafts) of 24 eyes with complications and 60% (3/5)
     resection, customized corneal graft, epikeratoplasty, amniotic           without complications were clear but the difference did not
     membrane transplantation, systemic steroids, cyclosporine,               reach statistical significance ( Pvalue = 0.07).
     azathioprine or cyclophosphamide.                                        Conclusion: Graft survival in Peter’s Anomaly carried poor
     Sixty-one (87%) eyes healed with corneal vascularization                 prognosis and majority of graft failures occured in the first
     and scarring after a mean follow-up period of 38 months                  two years. PKP in Peter’s anomaly was associated with a high
     (range 6-204 months). 19 (27%) eyes had corneal                          complication rate that compromised graft survival. Close
     perforation while on treatment. Thirty-three (47%) eyes had              follow-up in the first two years is mandatory to promptly
     a final visual acuity of 20/200 or worse, 33 (47%) eyes were             detect and treat complications as they arise and to improve
     better than 20/200 and 4 (4.5%) eyes had no light perception             the graft survival outcome.
     (3 were eviscerated). Thirty-seven eyes received
     immunosuppressive therapy,15 (40.5% ) eyes had a visual
     acuity of 20/200 or worse, 21 (56%) eyes had a better than               INTRALASIK: One Year Experience in Riyadh
     20/200 visual acuity, and 1 (2.7%) eyes had no light
     perception. There was no statistically significant difference            Khaled Ahmed Abdelrahman
     in the disease severity and outcome between patients who
     had a bilateral disease or a unilateral disease (p = 0.7).               Purpose: To assess efficacy, stability, safety, and predictability

64                                       Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                Saudi Ophthalmology 2007
of the INTRALASIK as a new refractive technique.                                 Session S3A – Prevention of Blindness
Methods: 435 eyes of 220 patients, 156 males and 64
females. Myopia range was (- 0.50 to - 10.50 ), Astigmatism
was ( -.050 to -3.00 ) and Hyperopia range (till +5.50). Age             Screening for Diabetic Retinopathy: Comparative Study
group was from 17 to 46 years, U/P was between 470 and                   Between Hospital-Based (Urban) versus Community-Based
660 Microns. INTRALASIK surgery done by Intralase                        (Rural) Screening and Between Paying and Non-Paying Patients
machine followed by Excimer ablation. Follow-up time at
one day, three days, one week, one month and three months.               Tayyab Afghani
Results: From 435 eyes, epithelial abrasion 1.83%, flap
puncture 0.46%, minor flap torn 1.15%, minor decentration                Purpose: Comparison of prevalence of diabetes/diabetic
0.69%, striae 0.23%, foreign body 2.99%, long period of                  retinopathy between urban and rural population and
dryness 0.23%, lost one line of best corrected vision with               between paying and non-paying patients in a tertiary eye
no enhancement 3.44%, lost more than one line of best                    care hospital.
corrected vision and underwent enhancement 2.29%.                        Methods: A total of 79,194 people over 40 years old were
While, button holes, major fluctuations of flap thickness,               screened for diabetes both in the community and eye hospital
complete or irregular or partial cuts, epithelial ingrowth,              setting. Initial screening was carried out by urine dipstick
abortion of surgery, major flap decentration or major flap               followed by random blood sugar examination. A value ≥
torn, wrinkles, ectasia, infection and flap displacement or              140 mg/dl of blood sugar was considered positive for
lost, all were 0 %. Post-operative unaided visual acuity better          diabetes. All the diabetics were then examined for any
than 20/20 was 48.27%.                                                   evidence of diabetic retinopathy through indirect
Conclusion: INTRALASIK is a new promising technique                      ophthalmoscopy in a dilated pupil by a midlevel
for refractive surgery; it is very safe, stable, effective and           ophthalmologist. A Health Education campaign at public,
predictable.                                                             patient and professional level was also conducted.
                                                                         Results: The results of screening were analyzed for three
                                                                         distinct groups; rural population, hospital-based free patients
                                                                         (poor urban population) and hospital-based paying patients
  Session S1C Prevention of Blindness Course                             (affluent urban population). The prevalence of diabetes was
                                                                         found to be 9.12%, 10.34% and 18.57% in rural, poor
                                                                         urban and affluent urban groups respectively. The prevalence
Laser photocoagulation in Diabetic retinopathy                           of diabetic retinopathy in the total screened population in
                                                                         these three subgroups was 1.92%, 2.52% and 4.42%
Emad Abboud and Members of Vitreoretinal Division, KKESH                 respectively, while this prevalence in the diabetic population
                                                                         was 21.05%, 24.39% and 23.80% respectively. The cost
Background: Diabetes is expected to affect 300 million                   per person screened was $2.6 to $3.4, while the cost per
people by 2025. Diabetic retinopathy is a common                         diabetic identified was $26 to $28 and the cost per patient
complication. Laser photocoagulation is still the mainstay               of diabetic retinopathy identified was $108 to $135.
of the management of Diabetic retinopathy.                               Conclusion: The prevalence of diabetic retinopathy was two
Course duration: 60-90 minutes                                           times higher in the affluent urban population as compared
Course details:                                                          to poor urban or rural population. For each known diabetic,
A. Laser in Diabetic Macular edema                                       there were four previously undiscovered diabetics in the rural
     1. techniques                                                       population, and three previously undiscovered diabetics in
     2. results                                                          urban/hospital based population.
     3. complications
B. Laser in Proliferative Diabetic Retinopathy
     1. techniques                                                       Penetrating Keratoplasty in Congenital Glaucoma
     2. results
     3. complications                                                    Ali Al-Rajhi, Ali Al-Ghamdi and Michael D. Wagoner
C. The new PASCAL laser
     1. techniques                                                       Purpose: To evaluate graft survival and visual outcome after
     2. advantages                                                       penetrating keratoplasty (PKP) for corneal edema and/or
     3. preliminary experience will be shared                            opacification in congenital glaucoma (CG).
Comment: There are large numbers of patients with diabetic               Methods: Fifty consecutive PKP of 40 patients performed
retinopathy requiring laser treatment. Every ophthalmologist             on (19 males, 21 females) at KKESH for congenital
should be familiar and be able to perform laser treatment                glaucoma between January 1, 1993 and December 31, 2003
for this condition. Hence, the importance of this course.                were retrospectively reviewed. The mean age at surgery was

                                    Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                 65
     Saudi Ophthalmology 2007
     19 months (range, 2 to 92 months).                                         Subluxated lens, optic atrophy, Ptosis and high refractive
     Results: Grafts survived in 38% after a mean follow-up of                  errors. Among all, preventable and treatable (avoidable) cases
     39.2 months (range, 6-132 months). The probability of graft                were 25.47% of the whole sample.
     survival was 92% at 6 months, 62% at 12 months and 40%                     Conclusion: Genetically determined disorders are important
     at 24 months. There was no significant correlation between                 causes of visual impairment at Al-Noor Institute at Al-Hassa
     age at the time of surgery and graft survival. Major                       along with other causes. So genetic counseling and early eye
     complications included microbial keratitis (20 eyes),                      screening of children along with public education may help
     persistent epithelial defect with or without sterile ulceration            in the prevention of visual impairment.
     (5 eyes), endophthalmitis (4 eyes), and endothelial rejection
     (3 eyes). Microbial keratitis, with or without associated
     endophthalmitis, was significantly associated with an                      Prospective Screening of Premature Babies Using Retcam
     increased risk of graft failure (P = 0.04), as was poor post-              II: A Digital Wide-Angle Pediatric Fundus Camera
     operative control of intraocular pressure (P= 0.02). Nine
     eyes (18%) obtained ambulatory vision, but only one eye                    Ihab Saad Mahmoud Othman, Hany ElMekawey
     (2%) was better than 20/40.                                                ElMekawey, Ahmed Fouad, Mohamed Raslan and Sherif
     Conclusions: Although the prognosis for maintaining graft                  Khalifa
     clarity is fair at best, and the prospect for ambulatory vision
     is guarded, there is still sufficient justification for performing         Purpose: To prospectively evaluate fundus of premature
     these cases when the alternative is a guaranteed lifetime of               babies in incubators and documenting the findings.
     blindness. Preoperative and postoperative control of                       Methods: Using Retcam II, dilated fundus examination was
     intraocular pressure, prevention of microbial keratitis, and               performed in a neonatal ICU facility from April 2005 until
     aggressive management of amblyopia are essential to                        November 2006. Nine hundred eighty one children with
     optimize the prognosis for graft survival and good visual                  birth weight more or less than 1500gm, gestational age more
     outcome.                                                                   or less than 32 weeks and who received oxygen therapy where
                                                                                examined looking for ROP and any associated fundus
                                                                                findings. Evaluation was performed by ophthalmic residents
     Isolation of Avoidable Causes of Visual Impairment                         who were shortly trained on uses of Retcam II, and findings
     Among Students at Al-Noor Institute for the Blind                          were reviewed by one of the authors (ISMO).
     in Al-Ahsa, Saudi Arabia                                                   Results: The incidence of ROP in this cohort was 23 % of
                                                                                all examined babies and        60.5 % of premature babies.
     Muneera A. Al-Hussain, Ahmed A. Alkhawaja, Mohammed                        Interestingly enough, other incidental fundus changes
     Sarfaraz Khan and Ramzy A. Alsulaiman                                      including retinoblastoma, congenital toxoplasmosis, retinal
                                                                                and preretinal hemorrhages, retinal telangiectasia and others
     Purpose: To identify and determine the etiology of the major               were present in 10% of examined babies.
     avoidable (both preventable and treatable) causes of low                   Conclusion: Evaluation of premature babies for fundus
     vision among students at Al-Noor Institute for The Blind at                changes is an important step in comprehensive neonatal care.
     Al-Hassa. It considers the World Health Organization                       Using available technology was associated with reproducible
     (WHO) criteria for low vision type of visual impairment.                   results and short learning curve for residents, making it easier
     Design: Prospective, interventional, non-comparative study.                to apply the experience on a wider scale.
     Methods: By application of the WHO definition for low
     vision, complete ophthalmic examination of all the students
     at Al-Noor Institute for the Blind at Al-Hassa, who have                   The Magnitude of Diabetic Retinopathy in the
     visual acuity in either eye better than 20/400 (3/60) and                  Eastern Mediterranean Region (EMR)
     less than 20/60 (6/18) was done in the academic year 2006.
     Results: A total of 61 Saudi students (122 eyes) including                 Abdulhannan Choudhury and Abdulaziz Al Rajhi
     27 males (44.2%) and 34 females (55.7%) were examined.
     Age range from 6 to 22 years, mean age 14 years. 82 eyes                   Executive Summary: There are around 170 million people
     (67.2%) fall within WHO definition of low vision 12 eyes                   with diabetes posing a substantial economic burden. In
     (9.8%) have a visual acuity better than 20/60 (6/18) and 28                the Eastern Mediterranean Region (EMR) there is no
     eyes (23%) have a visual acuity less than 20/400 (3/60). 53                population based data but the prevalence is alarming,
     cases (87%) were found to be a products of consanguineous                  especially in GCC States (15-25%). Diabetic Retinopathy
     marriages. The main causes of visual impairment in this study              (DR) is the most common complication of diabetes and a
     were the hereditary retinal disorders. Other causes were                   leading cause of visual loss in the working age group. It is
     congenital glaucoma, congenital cataract, Aphakia,                         estimated that around 2 million people worldwide are blind

66                                         Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                               Saudi Ophthalmology 2007
due to DR and the number is increasing. People with diabetes            Keratoconic patients, especially the back optic zone radius
are estimated to be 25 times more likely to develop blindness           (BOZR).
than non-diabetics. Diabetes and its sight threatening                  Seventy new keratoconus patients (56 female, 14 male; mean
complications pose health and financial burdens on countries            age 19.5 (SD 5.0) years range 11-28 years) were recruited
with a high prevalence such as in Saudi Arabia where more               from referrals to the Department of Ophthalmology, Asir
than 400 millions are spent annually.                                   Central Hospital. Patients were classified for keratoconus
Methods: Available data†indicate that early detection                   severity according to keratometry readings, and then fitted
through primary health care (PHC) approach and early                    with multicurve (McGuire Steep or Regular), tricurve or
treatment of DR are absent or very limited in some of the               Percon continuous curve rigid lens designs. Patients also were
member countries in EMR, although some good models                      given a slit-lamp assessment and visual acuity check. The
but with limited population coverage are present in some                keratoconus severity strongly influences the optimum lens
countries. Affordable technology and trained human                      design and BOZR. Tricurve or multicurve lens designs are
resource remain a major challenge. There are guidelines for             better suited for advance cases, while Percon curve lenses
the clinical management of DR endorsed by WHO and                       are only suitable for very early stages of the disease.
published by the International Council of Ophthalmology
that may be used as the minimum standard in the EMR.
Many studies have observed that early detection and                     What is Orthokeratology? Is Orthokeratology Safe?
treatment of DR is hampered by the lack of awareness among
diabetic patients. Thus, the prevention of visual disability            Helen Swarbrick
from DR must include patient education and early detection.
Conclusions: Integrated PHC team approaches in DR                       This talk will introduce the topic of orthokeratology
require properly trained ophthalmologist and appropriate                (OK) or contact lens corneal refractive reshaping, by
technology. Advance cases require tertiary eye care services,           providing background on the technique. This will
which are limited in many countries in EMR. Unless we                   include discussion of the principles of contact lens design,
pay urgent attention to primary prevention, diet, physical              fitting and monitoring of OK patients, and will include a
activity, tight blood glucose and pressure control, blindness           presentation of clinical results from various studies
due to diabetes will continue to rise.                                  worldwide.
                                                                        There have been an alarming number of reports about serious
                                                                        adverse responses, including microbial keratitis, associated
                                                                        with overnight orthokeratology. Our analysis of these
              Session S3B - Optometry                                   reports, now totally over 100 cases worldwide, suggests that
                                                                        poor practitioner education, lack of appropriate patient
                                                                        instruction, poor patient compliance, and lack of aftercare
Defining the Shape of the Cornea                                        underlie the majority of these reports. Lessons learned from
                                                                        our analysis can be applied directly to ensure maximum safety
Helen Swarbrick                                                         for patients fitted with this contact lens modality.

The increasing use of corneal reshaping technologies,
whether surgical such as PRK and LASIK, or contact lens-
based, such as orthokeratology, has required a rethinking of                 Session S4A – Imaging in Ophthalmology
our understanding of corneal shape. This lecture will
summarize the different corneal shape indices used to
describe the shape of the cornea before and after reshaping             The Benefit of Ultrasound Biomicroscopy in
treatment. Recommendations will be made about                           Management of Descemet’s Membrane
appropriate parameters to use when describing unusual                   Detachment After Deep Sclerectomy with MMC
corneal shapes arising from these procedures.
                                                                        Essam Osman

Rigid Contact Lens Fitting in Saudi Arabian                             A 22-year old female Saudi developed total Descemets
Keratoconic Population                                                  Detachment (DD) after deep sclerectomy with
                                                                        viscocanalostomy and MMC. The diagnosis was settled by
Abdullah Al-Assiri                                                      the benefit of ultrasound biomicroscp (UBM).
                                                                        Purpose: To study similar cases which developed DD after
The selection of the contact lens design is essential for               deep sclerectomy and the modality of treatment, and the

                                   Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                67
     Saudi Ophthalmology 2007
     benefit of UBM in the diagnosis and treatment.                            dimensions of anterior ocular tumors, demonstrates
     Discussion for possible causes of the detachment                          extension within and posterior to the iris, and differentiates
     Methods: Female patient with advanced juvenile glaucoma                   solid from cystic lesions.
     underwent nonpenetrating deep sclerectomy glaucoma
     surgery with viscocanalostomy and using mitomycin C
     developed DD one week postoperative. The patient                          Comparison of Color Coded Maps of Computer-
     developed severe corneal odema hazy view to the anterior                  Assisted Videokeratographic Measurements
     segment a differential diagnosis of corneal edema was                     Between OPD Scan and Orbscan IIz in 1000 Eyes
     discussed. UBM showed total Descemets detachment and                      in Relation to Manifest Refraction
     injection of SF6 gas 10% was helpful for reposition of the
     detachment.                                                               Khaled Ahmed Abdelrahman
     Conclusion: UBM as a non invasive technique is helpful in
     the diagnosis of anterior segment disorder and SF6 gas is                 Methods: A comparative study between the two machines
     beneficial in management with good outcome.                               Orbscan IIz (Bausch & Lomb) Serial No. MO1042268 &
                                                                               OPD Scan (Nidek) Serial No. 10433 for the amount and
                                                                               axis of the cylinder in relation to the manifest refraction.
     OCT and USG (Combined) for Ocular Tumors                                  Results :Age group was between 12 years and 66 years. 1000
                                                                               eyes of 525 patients. 171 females and 354 males. Amount of
     Arun Singh                                                                the cylinder varies from (0) to (-7.25) D. Amount of the
                                                                               sphere varies from (+8.00) D to (-11.00) D. Probability of
     Learning Objectives: At the conclusion of this presentation,              comparison between the two mean differences for the axis (
     participants will be able to:                                             P ) = 0.011283 ( < 0.05 ) which means : there is a difference
        • Describe basic principles of OCT and USG                             between both with regards to the axis of the cylinder.
        • Identify appropriate indications for these techniques                Probability of comparison between the two mean differences
        • Review diagnostic features of some specific entities                 for the power ( P ) = 0.165786 ( > 0.05 ) which means : there
     Abstract:                                                                 is no difference with regards to the power of the cylinder.
     There have been impressive advances in ocular imaging                     Conclusion: Both machines were equal with regards to the
     during the past few years, with digital imaging, wide-angle               power of the cylinder in comparison to manifest refraction
     photography, optical coherence tomography, and high-                      (subjective). OPD is superior to Orbscan with regards to
     resolution ultrasonography being just a few examples of such              the axis of the cylinder in comparison to manifest refraction
     progress.                                                                 (subjective).
     Optical Coherence Tomography:
     The anterior segment optical coherence tomography (AS-
     OCT) (Carl Zeiss Meditech Inc., Dublin CA) is a non-                      Confocal Microscopy of Corneal Dystrophies
     contact prototype which can be used in slit-lamp or
     transcleral modes to obtain real-time images of cornea, sclera,           Ali Al-Rajhi
     anterior chamber angle, iris, and lens. Posterior segment
     optical coherence tomography (OCT) demonstrates the fine                  To report confocal microscopy (CM) findings in corneal
     anatomical structure of the vitreoretinal interface, retina,              dystrophies (CD).
     and retinal pigment epithelium; however, deeper tissues are               Methods: Confocal scanning microscopy was done using
     not shown. OCT seems to be of little value in the differential            confocscan-3 from Nidek in total of 28 eyes ( 20 eyes with
     diagnosis of choroidal tumors.                                            CHED and 8 eyes with macular corneal dystrophy (MCD)).
     Ultrasonography:                                                          Results: CHED findings include superficial epithelial
     Ultrasonography imaging with A and B scan techniques is                   pleomorphism and polymegathism, with intraepithelial
     currently the most useful imaging technique in the                        bullae and there were no bullae at basal epithelial cells with
     management of patients with uveal tumors. It enables                      well defined borders. Hyper-reflective nuclei of keratocytes
     detection of a tumor when the media are opaque, provides                  was seen in 4 eyes (23%). Low endothelial cell density with
     diagnostic clues and defines the extent of the tumor both                 pleomorphism, polymegathism but no guttata in all 5
     within the eye and extra-ocularly. Color Doppler imaging                  examined eyes. MCD showed high reflective lesions at the
     demonstrates intrinsic circulation which can help                         level of epithelium and superficial stroma and to a less extent
     differentiate a neoplastic tumor from a simulating lesion,                posterior stroma. Endothelial cells and keratocytes exhibited
     such as a hematoma. Ultrasound biomicroscopy is                           high reflectivity also. No abnormal findings were detected
     performed with a high-frequency probe (e.g. 20 MHz) and                   in grafts of MCD cases to detect subclinical evidence of
     images the anterior part of the eye with a very high resolution.          recurrence.
     Unlike standard ultrasonography, it precisely measures                    Conclusions: CM is a non-invasive tool to image cellular

68                                        Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                Saudi Ophthalmology 2007
and extracellular structures throughout corneal layers. Size,            of the optic nerve. As glaucoma patients have a different
location of bullae with abnormal cellular size, shape and                visual sensitivity and variable fields. The aim of this study is
density can be detected in CHED. MCD lesions involve                     to describe the visual sensations experienced by patients
all layers of the cornea including endothelium, and CF can               undergoing glaucoma filtration surgery under peribulbar
be useful to detect MCD lesions in cornea and grafts.                    anesthesia.
                                                                         Materials and Methods: This prospective, non-randomized
                                                                         study was conducted at the King Khaled Eye Specialist
                                                                         Hospital. Seventy five adult patients of ASA status I to III
              Session S4B – Free Papers                                  who were scheduled for filtration procedure under local
                                                                         anesthesia were recruited. Patients were classified for 3 groups
                                                                         according to the severity of glaucoma. A peribulbar block
Frontalis Muscle Flap for Correction Of Ptosis                           was given using an inferotemporal approach injecting 10
                                                                         ml of local anesthetic solution. if akinesia was inadequate, a
Mostafa A. Elewa and Hesham Elmazar                                      second injection of between 3 to 5 ml was given using a
                                                                         superomedial approach. Participants were interviewed within
Purpose: To evaluate the technique of frontalis muscle flap              2 hours after the surgery using a standardized questionnaire.
in cases of severe ptosis with poor or no levator function.              Results: Sixty five patients (86.7%) perceived light
Patients and Methods: The study included 12 lids of 11                   perception during the surgery, while the remaining ten
patients with severe ptosis. Frontalis muscle flap was                   (13.3%) lost light perception. Forty six patients (61.3%)
fashioned and sutured directly to the tarsus. Follow-up                  were able to perceive colors. Thirty-two patients (42.7%)
extended up to 18 months.                                                perceived movement. One patient (1.3%) was frightened
Results: A good cosmetic result was achieved in most of the              by his intraoperative visual experience. Of the remaining
cases with one case of recurrence corrected later on by fascia           patients, fifty- three (70.7%) said the visual sensations were
lata sling.                                                              “fine” while twenty one (28.0%) found them unpleasant.
Conclusion: Frontalis muscle flap is a good alternative to               Conclusion: Majority of patients undergoing glaucoma
fascia lata sling in cases with severe ptosis.                           filtration surgery retain light perception intraoperatively and
                                                                         many experience various visual sensations.

Traumatic Corneal Epithelial Cyst
                                                                         Deep Sclerectomy in Uveitic Glaucoma
Adbul Elah Al-Towerki and Ghada Al-Bin Ali
                                                                         Saleh Al-Obeidan, Abdulrahman Al-Muammar, Ahmed Abu
Purpose: To report a case of corneal epithelial cyst following           El-Asrar and Essam Osman
Method: Case report                                                      Background/Aim: Success rate of trabeculectomy in uveitic
Results: Painless corneal lesion covers most of the cornea in            glaucoma is much less than in ordinary glaucoma cases. In
the right eye. The mass was noted following right eye trauma             this prospective study, we examined the safety and efficacy
four (4) months back where it enlarged quickly over the last             of deep sclerectomy (DS) for the treatment of uveitic
month. Simple excision of the corneal cyst performed                     glaucoma resistant to medical therapy. Patients and
without recurrence for more than two (2) years.                          Methods: Eight patients (thirteen eyes) with chronic uveitis
Conclusion: Simple excision of anterior stromal epithelial               were included (mean age 25.1+ 13.7, range 10-57 years).
cyst performed in the young lady with no recurrence for                  All patients had their uveitis controlled with
more than two (2) years.                                                 immunosuppressive and/or immunomodulatory therapy
                                                                         before and after surgery. Deep Sclerectomy with drainage
                                                                         device (T-flux IOLtech) and mitomycin was performed in
Subjective Visual Sensation During Glaucoma Surgery                      all eyes.
Under Local Anesthesia                                                   Results: Intraocular pressure (IOP) was reduced from a
                                                                         mean pre-operative value of 31.15 + 6.34mmHg to a mean
Waleed Riad Soliman, Colin Tan, Chandra Kumar and Kah-                   post-operative value of 13.07+ 1.55mmHg at a mean follow-
Guan Au Eong                                                             up of 13.7+ 10.29 months, (range 6-36 months). Complete
                                                                         success was achieved in 11 (84.6%) eyes and equalified
Background and Goal of Study: Visual experiences vary                    success in 1 (7.7%) eye. One (7.7%) eye had a complete
during cataract surgery under retrobulbar and peribulbar                 failure. Post-operative complications included increased
blocks. Sensation may be impaired due to injection and                   cataract in 6 eyes, transient hypotony maculopathy in 3 eyes,
spread of the local anesthetic agent into the close proximity            choroidal detachment in 2 eyes which resolved within 10

                                    Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                  69
     Saudi Ophthalmology 2007
     days and small hyphema in one eye.                                        (100%), and 6 (42.9%) membranes, respectively. There was
     Conclusion: Deep sclerectomy controlled the IOP in 92.3%                  a significant correlation between the number of blood vessels
     of eyes with uveitic glaucoma resistant to medical therapy.               expressing the panendothelial marker CD34 and the number
     Rate of surgical complications that can affect the surgical               of blood vessels expressing CTGF (r = 0.7884; p = 0.0008),
     outcome was low which may explain the high success rate                   and CD105 (r = 0.6901; p = 0.0063), and the number of
     of the procedure compared to classical trabeculectomy.                    myofibroblasts expressing CTGF (r = 0.5922; p = 0.0257).
                                                                               There was a significant correlation between the number of
                                                                               myofibroblasts expressing a-SMA and the number of
     Reversal of Visual Loss Due to Optic Neuropathy                           myofibroblaasts expressing CTGF (r=0.8393; p=0.0002).
     and Exudative Retinal Detachment After Closure of                         In situ, zymography showed the presence of gelatinolytic
     a Traumatic Carotid-Cavernous Fistula                                     activity in vascular endothelial cells in PDR membranes.
                                                                               Myofibroblasts in PVR membranes expressed CTGF, and
     Abdullah M. Al-Fawaz, Ghada Y. Al-Bin-Ali, and Ahmed                      gelatinase B.
     M. Abu El-Asrar                                                           Conclusions: These results suggest a possible role of CTGF,
                                                                               CD105, and gelatinase B in the pathogenesis of proliferative
     Purpose: To report a case of traumatic carotid-cavernous                  vitreoretinal disorders.
     fistula (CCF) in which loss of vision was reversed after closure
     of the fistula.
     Methods: Case report.                                                     The “Suck And Cut”: A New Bimanual Technique
     Results: A 15-year-old female had a 12-day history of visual              for Delamination of Fibrovascular Membranes in
     loss, proptosis, and redness in the right eye after sustaining            Proliferative Diabetic Retinopathy
     trauma to the head from a road traffic accident. Examination
     revealed the presence of optic neuropathy and exudative                   Radhwan A. Cheema
     retinal detachment. Angiography demonstrated a CCF.
     Vision was completely restored and exudative retinal                      Delamination of fibrovascular membranes in diabetic
     detachment resolved after closure of the fistula.                         retinopathy can be difficult. With the help of video, a new
     Conclusion: Although CCFs frequently are associated with                  bimanual technique is described, where suction is applied
     permanent visual loss, a subset of patients demonstrates                  with a vitrector in a controlled manner to manipulate tissues
     reversible ocular findings.                                               for delamination which is easier to master than conventional
                                                                               vitreo-retinal techniques.

     Expression of Angiogenic and Fibrogenic Factors in
     Proliferative Vitreoretinal Disorders                                     Intravitreal Avastin: Six months’ experience at
                                                                               Dhahran Eye Specialist Hospital
     Ahmed M. Abu El-Asrar, P.E. Van den Steen, S.A. Al-Amro,
     L. Missotten, G. Opdenakker, and K. Geboes                                Rao K. Madhav and Radhwan A. Cheema

     Purpose: To investigate the expression of connective tissue               Background/AIM: Many experimental and clinical studies
     growth factor (CTGF) in the retinas from human subjects                   have implicated vascular endothelial growth factor (VEGF)
     with diabetes mellitus, and CTGF, CD105, and gelatinase                   in the pathogenesis of ocular neovascularization.
     B in proliferative diabetic retinopathy (PDR) and                         Bevacizumab (avastin) is a humanized monoclonal antibody
     proliferative vitreoretinopathy (PVR) epiretinal membranes.               that prevents formation of new blood vessels by targeting
     Methods: Twelve donor eyes from six subjects with diabetes                and inhibiting the function of VEGF. The aim of this study
     mellitus, ten eyes from five nondiabetic subjects, 14 PDR                 is to share our initial experience in the use of intravitreal
     membranes, and 5 PVR membranes were studied by                            ‘avastin’ in various vascular ocular disorders and report on
     immunohistochemical techniques. In situ, zymography was                   its efficacy and safety.
     used to examine gelatinolytic activity in 4 PDR membranes.                Design: Interventional, retrospective case series.
     Results: In non-diabetic retinas, there was no                            Methods: 18 patients and 24 eyes. Complete ophthalmic
     immunoreactivity for CTGF. Diabetic retinas showed                        evaluation included Snellen visual acuity, color fundus
     immunoreactivity for CTGF in ganglion cells and microglia.                photographs, FFA and OCT. Patients received intravitreal
     Vascular endothelial cells in PDR membranes expressed                     Bevacizumab (Avastin) 1.25 mg /0.05ml in wet macular
     CTGF, CD105, and gelatinase B in 10 (71.4%), 11 (78.6%),                  degeneration (CNV), proliferative diabetic retinopathy,
     and 5 (35.7%) membranes, respectively. Myofibroblasts in                  neovascular glaucoma, diabetic macular edema, CRVO and
     PDR membranes expressed CTGF, and gelatinase B in 14                      macular edema secondary to retinal vein occlusion.

70                                        Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                  Saudi Ophthalmology 2007
Results: Most patients showed improvement or stabilization                 Bilateral “Very late onset” Cystoid Macular Edema
of visual acuity, regression of rubeosis, regression of retinal/           After Uncomplicated Phacoemulsification
disc neovascularization and decrease in retinal thickness. No
significant local or systemic side effects were encountered.               Essam Al-Harthi
Conclusion: ‘Avastin’ is beneficial and safe in a variety of
vascular ocular conditions. Further randomized controlled                  This a case of bilateral CME developed 16 years after
trials should be conducted to evaluate potential of this therapy.          uncomplicated Phacoemulsification
                                                                           OCT and FFA which demonstrates clearly the presence of
                                                                           CME. This is the first case reported following
Choroidal Neovascular Membrane Secondary to                                Phacoemulsification after this length of time.
Choroidal Osteoma Successfully Treated with                                Conclusion: CME should be considered in patients
Bevacizumab in Two Patients                                                following uncomplicated cataract surgery with visual loss
                                                                           even 16 years after.
Emad B. Abboud, Eman Al-Kahtani and Abdullah Al-Kharashi

Background: Recently, intravitreal Bevacizumab was found                   Long-Term Safety and Efficacy of Infliximab Therapy
effective in controlling Choroidal Neovascular membranes                   in Refractory Uveitis Due to Behcet’s Disease
complicating Age-Related Macular Degeneration.
Purpose: To report two cases of Choroidal Neovascular                      Ahmed M. Abu El-Asrar, Emad B. Abboud, Hassan Al
Membrane CNVM complicating Choroidal Osteoma,                              Dhibi, and Abdulrahman Al-Arfaj
which were successfully managed by Intravitreal
Bevacizumab.                                                               Purpose: To evaluate the long-term safety and efficacy of
Case 1: 23 year old female patient, known to have decreased                infliximab therapy for refractory uveitis associated with
vision in the left eye, presented with a one month history of              Behcet’s disease.
further deterioration, as well as metamorphopsia. The left                 Methods: We prospectively enrolled 6 patients who failed to
eye was found to have a macular choroidal osteoma                          respond to conventional immunosuppressive treatment.
complicated by a subfoveal classic CNVM.                                   Infliximab infusions (5 mg/Kg) were administered at weeks 0,
She was managed by two intravitreal Bevacizumab 1.25 mg/                   2, 6, and then every 8 weeks. The outcome variables were visual
                                                                           acuity, control of inflammation, reduction of macular edema,
0.05 ml injections, one month apart. One month after the
                                                                           tapering of immunosuppressive therapy, and adverse effects.
first injection, the CNVM was demonstrated to be
                                                                           Results: The follow-up period ranged from 16 to 36 months
completely inactive. Three months after the second injection,
                                                                           (mean ± SD, 23 ± 7.4). The number of infliximab infusions
the CNVM stayed completely inactive.
                                                                           ranged from 10 to 23 (mean ± SD, 14 ± 4.6). By the 2-
Case 2: 38 year old female patient, complaining of decreased
                                                                           month follow-up, all patients achieved remission, cystoid
vision in the right eye for one month duration. The right
                                                                           macular edema resolved, and their visual acuity improved
eye was found to have a macular choroidal osteoma                          dramatically. Throughout the follow-up period, 3 patients
complicated by CNVM .                                                      remained attack-free. One patient had one relapse, and
She was managed by three intravitreal Bevacizumab 1.25                     another patient had 2 relapses before the scheduled infusions
mg/0.05 ml injections, one month apart. One month after                    that resolved rapidly after the subsequent infusion. One
the third injection, the CNVM was demonstrated to be                       patient developed 5 relapses and infusions of 6-week intervals
completely inactive.                                                       were necessary to achieve sustained remission. At the end of
Conclusion: To the best of our knowledge, these are the                    follow-up, visual acuity improved in 5 patients. Concomitant
first cases of CNVM complicating choroidal osteoma to be                   immunosuppressive therapy was substantially reduced.
successfully managed with intravitreal Bevacizumab. The                    Antinuclear antibodies developed in 2 patients who received
latter should be considered in the management options of                   17 and 23 infusions. No major adverse effects requiring
these neovascular membranes                                                withdrawal of infliximab were observed.

                                      Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                 71
     Saudi Ophthalmology 2007

                       MONDAY, MARCH 5                                            developed diabetes mellitus, Celiac disease and
                                                                                  hypothyroidism, and three patients had asthma.
                                                                                  Conclusions: VKH in children may present with clinical
          Session M1A – Pediatric Ophthalmology
                                                                                  findings consisting of bilateral panuveitis without the major
                                                                                  clinical manifestations of VKH such poliosis and vitiligo.
                                                                                  The disease may be blinding unless children are given early
     Aspects of the Management of Third Nerve Palsy                               and aggressive treatment for their uveitis. Certain associated
                                                                                  clinical findings such as diabetes mellitus, Celiac disease and
     Anthony Murray                                                               other autoimmune diseases may be seen in patients with
                                                                                  VKH. In addition, we have encountered tumors of the
     Third Nerve palsies may be total or partial. Knowing the                     central nervous system associated with VKH.
     aetiology of third nerve palsy assists in developing strategies
     for management. In children, congenital factors, including
     birth trauma and neonatal hypoxia, are the leading causes                    Tales of the Unexpected
     of third nerve palsy. In adults, the most common causes are
     aneurysm and vascular disease. Trauma is a fairly common                     Anthony Murray
     cause of acquired third nerve palsy in both adults and
     children. An approach to the evaluation and management                       Our understanding of the aetiology and management of
     of patients with third nerve palsy will be presented.                        some forms of strabismus has changed significantly over the
                                                                                  past 10 years. In infants with infantile esotropia, initial
                                                                                  alignment with one procedure can be expected in 70% -
     Pediatric Vogt-Koyanagi-Harada                                               100% of patients. Over their lifetime, on average, 1.9 – 2.6
                                                                                  operations are required. If adjustable sutures are utilized,
     Khalid F. Tabbara                                                            surgical alignment in adults can be achieved with one
                                                                                  procedure, in 70% to 90% of patients. In some patients,
     Backgound/Objective: Vogt-Koyanagi-Harada (VKH) is a                         the expected result is not achieved. Some of these patients
     multi-system autoimmune disorder characterized by an                         as well as other unusual patients will be presented.
     immune-mediated insult to melanin-bearing cells. The
     pigmented tissues in the ocular, auditory, integumentary and
     central nervous systems are affected. The disease affects                    Neuro-Ophthalmology Clinical Diagnosis
     individuals in the third and fourth decade of life. VKH in
     children is uncommon. In Saudi Arabia, however, VKH may                      David Taylor
     affect patients in the first decade of life. A new devised diagnostic
     criteria for VKH has classified the disease into complete,                   The importance of neuro-ophthalmology in paediatric
     incomplete or probable based on the presence of extraocular                  Ophthalmology
     findings. The main objective of this presentation is to discuss              History
     the features and associated clinical findings of VKH in children.            Examination: Age-appropriate tests; The whole child;
     Patients and Methods: The records of 16 cases with pediatric                               Refraction
     VKH disease were reviewed. The onset of the disease was                      Visual perception
     prior to the 18th birthday. The clinical findings were studied               Visual Agnosias and Blindsight
     in all patients.                                                             Testing children
     Results: There were 4 males and 12 females. Cataract surgery                 Subtle chiasmal signs
     was performed on 11 out of the 16 patients. Optic nerve                      Pupils
     head edema, subretinal neovascularization and glaucoma                       Some ‘Golden Rules’
     were common in children. Major sequelae of VKH in
     children include retinal pigment epithelial changes, cataract,
     retinochoroiditic scars, subretinal neovascular membranes,                   Session M1B – Cornea & Refractive Surgery Course
     glaucoma and phthisis bulbi. Ocular findings in pediatric
     VKH may appear prior to the onset of systemic disease and                    ICL Surgery: Tips, Tricks and Special Indications
     may present a challenging clinical problem before the onset
     of poliosis, vitiligo and other manifestations of VKH. Four                  John Vukich
     cases had associated central nervous system (CNS) tumors
     consisting of pituitary adenoma, arachnoid cyst,                             This course will provide an overview of ICL surgery technique
     chondrofibromyxoma and Hodgkin’s lymphoma. In                                and focus on incorporating tips to maximize outcomes. Topics
     addition, we found out one patient, a 3 year-old, who                        to be discussed include developing nomograms for specific

72                                           Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                   Saudi Ophthalmology 2007
patients, improving practice flow, utilizing toric ICLs to                  successfully worn contact lenses in their younger years
improve results, and managing patient education of phakic                   desire to continue with contact lens wear. However, gradual
IOLs. At the conclusion of the course, attendees will be able               changes in anterior eye structure and function may impact
to improve and optimize the applications of Implantable                     on the continuing success of these experienced contact lens
Collamer Lenses into their practices.                                       wearers, and should also be considered when introducing
                                                                            presbyopes to contact lens wear. This lecture will describe
                                                                            aging changes in the cornea, conjunctiva, tear film, and
                                                                            adnexa that may impact on the success of contact lens wear
               Session M1C - Optometry                                      in the older patient.

Emmetropization and Refractive Error Corrections                            Prescribing Glasses for Children
in Young Children
                                                                            Al-Annoud Al-Molafkh
Sandra Block
                                                                            Prescribing glasses for children can be very challenging due
This lecture will present the changes in refractive error which             to various considerations that take place within this age
occur as result of changes that take place in the ocular                    group. This presentation will highlight the purpose of
structure from birth through the first decade of life. In                   prescribing in children, as well as the most common
addition, case examples will be used to demonstrate when                    problems seen in children using glasses; the last part will
to correct refractive errors and how much should be                         highlight the new available options for children’s glasses in
considered at different ages.                                               the market.

Vision Training for Pseudomyopic Teenagers                                  Diagnosis Common Binocular Vision Anomalies in
                                                                            a Primary Care Pediatric Exam
Musa Zaiyd
                                                                            Sandra Block
Pseudomyopia due to spasm of accommodation has been
increased significantly over the last few years. Eye glasses alone
                                                                            This presentation will review what information that can
cannot improve the vision in such cases. Simple straight vision
training and visual hygiene will control the progression of the             be drawn from the primary care exam along with
problem and improve the vision significantly to normal                      suggested techniques to assess the more common vision
uncorrected vision. Several interesting cases will be discussed and         problems found in children. Highlights of the case
a special regimen will be provided to treat these cases effectively.        history, visual acuity testing, refractive error assessment,
                                                                            along with techniques used to investigate
                                                                            accommodation, fusion, and strength of binocularity will
Integrating the Care of the Infant, Toddler, and                            be reviewed.
Preschooler into a Primary Care Practice

Sandra Block
                                                                            Myopia Control: An Update

This presentation will show how to evaluate the vision of an                Helen Swarbrick
infant, toddler and preschooler. A review of techniques that
provide information about visual acuity, accommodation,                     The increasing prevalence of myopia worldwide has
refractive errors, binocularity, and eye health along with their            stimulated renewed interest in possible approaches to the
strengths and limitations will be included.                                 control of myopia progression in children. This talk will
                                                                            review the different approaches that have been used, and
                                                                            are in use in different regions of the world. The relative
The Older Patient in Contact Lens Wear –                                    efficacy of these different techniques, based on controlled
                                                                            clinical trials, will be discussed, and promising new
Physiological Considerations
                                                                            approaches will be presented.
Helen Swarbrick

The population is aging and many older patients who have

                                       Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                               73
     Saudi Ophthalmology 2007

         Session M2A – Pediatric Ophthalmology                                                  Session M2C - Optometry

     Refinement of screening guidelines for ROP in
     Saudi Arabia - Is it needed ?                                            Cosmetic Contact Lens: Alternative to Surgical
     Ishraq Tashkandi
                                                                              Imtiaz Chaudhry
     Screening for retinopathy of prematurity ROP was started
     in many countries at the end of 1980s.                                   Absolute indication for enucleation includes eyes with
     The aim of the screening program is to detect infants needing            known or suspected intraocular malignancy not amenable
     treatment for ROP & hence to minimize visual disability &                to any other form of therapy, and no-seeing eyes following a
     ocular morbidity. National variations in genetics, neonatal              major perforation. Indications for evisceration include
     care and general health care, socioeconomic factors, etc.,               patients with bleeding disorders, untreated endophthalmitis
     make it necessary to adopt screening guidelines to each                  and patients who desire superior cosmesis for unsightly non-
     country and to revise them regularly.                                    seeing eyes.
     Methods: Three Saudi premature infants (GA 33-34 weeks),                  Alternatives to enucleation and evisceration include
     two of them are twins, diagnosed as unoperable funnel-                   conjunctival flaps and corneal tattoos in those eyes which
     shaped retinal detachment and flat ERG, their birth weights              do not have to be removed or eviscerated. Also, cosmetic
     were 1400g and 1500g with an uneventful medical course,                  contact lenses are an excellent alternative for non-seeing
     no use of heavy oxygen therapy, and they were only referred              unsightly eyes when there is an acceptable ocular surface
     to an ophthalmologist at the age of 10 weeks when the                    with adequate volume and patient is able to wear them
     pediatrician suspected leucokoria. A third case came for a               comfortably. All of these options will be highlighted in this
     second opinion with similar history and findings.                        presentation.
     Conclusion: The observation of three cases only is not enough
     to reach to the evidence for the need to refine the screening
     guidelines for ROP. The existing guidelines recommended by               Do Tinted Hydrogel Prosthetic Lenses Really Help?
     the Canadian Pediatric Society CPS and the American
     Academy of Pediatrics AAP for routine screening for ROP                  Ali Bukhamseen
     remains controversial. Most of the recent studies
     recommended lowering of the screening criteria as their studies          Many different injuries, conditions, or infections can lead
     showed no infant with severe ROP would have been missed.                 to disfigurement of the anterior segment of the eye and leave
     I suggest that we in Saudi Arabia need to adopt screening                an individual feeling self-conscious about their appearance.
     guidelines with periodic revision and to have a cost-effective           Prosthetic hydrogel lenses, either pre-made or hand-painted,
     strategy at the same time to minimize missed cases which                 designed to match the other eye as closely as possible, can
     certainly need a prospective consecutive multicentral study.             make the disfigured eye less conspicuous. Certain eye
                                                                              conditions and accompanying disfigurements that may
                                                                              benefit from the use of a prosthetic contact lens include:
                                                                              disfigurement of the cornea, aniridia, albinism, photophobia,
      Session M2B- Cornea and Refractive Surgery                              nystagmus and amblyopia. Digital photography has made
                                                                              hand-painted prosthetic lenses much easier than before and
                                                                              relay more accurate color matches to CL manufacturers.
     Corneal Topography Made Simple                                           Good centration with minimal movement is critical in order
                                                                              to obtain the best cosmetic results.
     John Vukich

     This course will provide an overview of corneal topography               Introduction to Ocular Prostheses
     and focus on incorporating tips to identify suspect patterns.
     Topics to be discussed include case reports of specific                  Mohammad Badran
     patients, analysis of patients who went on to develop ectasia
     following LASIK surgery, and utilizing topography to guide               The goal of fitting the ocular prostheses is to return the
     selection of the optimal refractive proceedure. At the                   patient to a normal appearance and lifestyle. Modern
     conclusion of the course, attendees will be able to improve              custom-made ocular prostheses can give the patient an
     and optimize the use of corneal topography in their practices.           excellent physical and cosmetic appearance. In the final

74                                       Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                   Saudi Ophthalmology 2007
analysis, the success or failure of the long-term use of the                Conclusion: Fourier features are an accurate and repeatable
prostheses depends on the proper fit and the patient’s                      representation of the visual system that reveal more detail
cooperation in caring for his/her prosthetic eye.                           than can be reconstructed with 6th order Zernikes. Fourier-
                                                                            driven ablations provide excellent clinical results.

Special Design Iris Tinted Contact Lens Fitting for
Albino Patients                                                             Predictability of 110 Microns Flap Thickness of the
                                                                            INTRALASE in 100 Myopic Eyes
Musa Zaiyd
                                                                            Khaled Ahmed Abdelrahman
Iris transillumination is a common defect in Albino patients;
decreased vision and severe photophobia are the main                        Purpose: To estimate the accuracy and predictability of the
complaints of the patients. Unfortunately, there are no                     thickness of Flap cut by INTRALASE at 110 microns thick
medications or surgery that can help such cases. Tinted eye                 in 100 eyes.
glasses may reduce the photophobia but they don’t improve                   Methods: This study was done on 52 consecutive patients,
visual efficiency. A custom design iris tint contact lens has               40 males and 12 females. The mean patient’s age was 25
been tried in this study. We will discuss in detail how these               years old. Myopia ranged from -0.50 to -10.50 Diopeters,
tinted lenses combined with precise measurements of pupil                   astigmatism was less than 3 Diopters. Flaps were cut by
size and iris diameter will improve the visual efficiency and               INTRALASE CORP. with SN: 0205 20097 at 110 microns
reduce photophobia in these cases.                                          with preoperative ultrasonic pachymeter and intraoperative
                                                                            ultrasonic pachymeter for the bed after flap lift by NIDEK
                                                                            UP 1000 with SN:20477, then calculations done for the
                                                                            actual flap thickness.
         Session M3A – Refractive Surgery                                   Results: Average flap thickness was significantly less than
                                                                            110 microns. Average flap thickness for all of the right eyes
                                                                            was 96 microns and for all of the left eyes was 102 microns.
Fourier versus Zernicke: Strengths and Limitations of                       Conclusion: Actual INTRALASE flap thickness is
Two Methods of Wavefront Reconstruction Purpose                             significantly less than as expected.

John Vukich
                                                                            Corneal flap thickness in laser in-situ
This review of the two leading methods for describing                       keratomileusis using Moria M2 microkeratome
wavefront data will address how Fourier and Zernike                         single use head
algorithms are derived, their suitability for fitting complex
shapes, repeatability, and theoretical and clinical accuracy.               A.Al-Muammar and M. Farooqui
Methods: Zernike-based algorithms rely on complex
mathematics to split the visual system into individual                      Purpose: To determine the predictability of flap thickness
polynomial terms and reconstruct a wavefront that may be                    in laser in-situ keratomileusis using the Moria M2
limited by the smoothing effects of the algorithm. A newer                  microkeratome single use 130 head and identify factors that
method of analysis, Fourier, uses sine waves to build the                   may be related to variation in flap thickness.
wavefront, with waves of varying frequency and amplitude used               Design: Prospective non-comparative interventional case
to describe more complex shapes. Clinical results, as well as               series.
data from a study evaluating residual error in lenslet recalculation        Methods: Sixty-four eyes of thirty-six patients underwent
in normal and postoperative eyes from Fourier, Zernike 6th order,           laser in situ keratomileusis. All flaps were created using Moria
and Zernike 10th order analyses will be presented.                          M2 Microkeratome single use 130 head. Cornea flap
Results: The method of data analysis (Zernike or Fourier)                   thickness was measured by subtracting the intraoperative
does affect both the wavefront shape and the point-spread                   central corneal bed pachymetry from the preoperative central
function. In elliptical pupils, Fourier transform allows                    corneal pachymetry. Variables examined included age,
analysis of peripheral data that would be ignored by Zernike.               preoperative corneal thickness, preoperative average
Analyses consistently show that the size, orientation, and                  keratometry power and preoperative spherical equivalent.
aberration shape in Fourier-calculated wavefront maps is                    Results: Mean flap thickness was 130.7 ± 27.35 µm (range
accurate and repeatable. By comparison, the smoothing                       69 to 188 µm). The actual flap thickness was not statistically
effects of Zernike-based algorithms limit the accuracy of                   different from the predicted flap thickness. The difference
these algorithms, especially in very complex eyes.                          in flap thickness between the right and left eye was not

                                       Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                  75
     Saudi Ophthalmology 2007
     statistically different (P > 0.05). There was a positive                 aberration (P = 0.024), secondary astigmatism (P = 0.013),
     correlation between flap thickness and preoperative corneal              and total RMS (P = 0.03) than WFO LASIK while trefoil
     thickness (P< 0.01). There was no correlation between flap               (P = 0.2) and quadrafoil (P = 0.1) were non-significantly
     thickness and keratometry, refractive error, or age                      less after WFG LASIK than after WFO LASIK.
     Conclusion: The flap thickness with Moria M2 microkeratome               Conclusion: Wavefront-guided LASIK induced less higher
     single use 130 head has a large standard deviation and                   order aberrations than the wavefront-optimized LASIK,
     remarkable individual variation. Therefore, the intraoperative           especially spherical aberration, coma, and secondary
     calculation of the remaining stromal bed is recommended.                 astigmatism.

     The Role of Phakic IOLs in a Comprehensive
     Refractive Surgery Practice                                                  Session M3B – Imaging in Ophthalmology

     John Vukich
                                                                              Doppler Ultrasound of the Eye an Orbit
     Purpose: This presentation will examine the use of phakic
     IOLs (PIOL) as an alternative to corneal refractive surgery              Claude Jacquemin
     for the treatment of myopic astigmatism.
     Methods: Safety, efficacy and complication profiles of the               Normal orbital flow values are presented. Review of
     most commonly used anterior and posterior chamber PIOLs                  dopller results in a variety of pathological orbital and
     as reported from multi-center clinical trials will be reviewed.          ocular conditions. Vascular and non vascular orbit tumors
     New styles of angle supported PIOLs as well as toric posterior           and preliminary assesment of doppler findings in
     chamber phakic IOLs will be discussed. Global trends in                  Retinoblastomas. Lecture done using KKESH experience
     usage of phakic IOLs will be presented.                                  until 2003.
     Results: Globally, use of PIOLs has increased 30% per year
     for the past four consecutive years. Visual correction
     comparable to LASIK is reported for all types of phakic IOLs.            Retcam Uses in Vitreoretinal Surgery and Other
     Conclusion: Phakic IOLs have gained acceptance as an                     Non-Traditional Applications
     alternative to corneal ablation for the treatment of refractive
     errors. PIOLs hold promise for the treatment of atypical                 Ihab Saad Mahmoud Othman
     corneas with thin pachymetry or suspicious topography.
                                                                              Purpose: Retcam II is introduced as a tool for wide angle
                                                                              retinal imaging in pediatric age group. We evaluate the uses
     Wavefront-Optimized versus Wavefront-Guided LASIK                        of Retcam II in adult population.
     in the Treatment of Myopia and Myopic Astigmatism                        Methods: consecutive case series of adult cases with varying
                                                                              different retinal pathology were evaluated using wide field
     Alaa Ghaith and Mohamed El Kateb                                         fundus photography, fluorescein angiography video
     Purpose: To compare wavefront-optimized LASIK and                        Results: 25 cases with different retinal conditions were
     wavefront-guided LASIK in the treatment of myopia and                    evaluated. Age varied between 25 to 72 years. Patients were
     myopic astigmatism with regards to their effect on higher                phakic, with nuclear sclerosis, pseudophakic and aphakic.
     order aberrations.                                                       Retcam II was valuable in demonstrating a wide angle fundus
     Methods: Thirty eyes had wavefront-optimized LASIK using                 photography in patients with diffuse pathology. Interventional
     the standard software of the Allegretto platform and 30 eyes             photography was done performing fine needle biopsy.
     had wavefront-guided LASIK using the CustomVue
     technique of the VISX Star S4 platfrom. Higher order
     aberrations were measured preoperatively as well as 3 months             Microphtalmus With and Without Cyst
     postoperatively using Hartman-Shack-based WaveScan
     aberrometer.                                                             Claude Jacquemin
     Results: The mean spherical equivalent of manifest refraction
     (MRSE) in the WFO group was -4.746 ± 0.59 D (range -                     Microphtalmus with and without cysts. Physiopathology
     1.735 D to -9.48 D) while in the WFG group it was -4.33                  and challenge for orbit reconstruction. What information
     ± 1.23 D (from -1.25 D to -9.12 D). WFG LASIK                            should include a CT [ or MRI] report? Lecture based on
     produced significantly less coma (P= 0.01), spherical                    KKESH cases 2003-2006.

76                                       Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                  Saudi Ophthalmology 2007
Fluorescein and Indocyanine Green Angiographic                             March 2006 to end of October 2006.
Studies for Ocular Tumors                                                  Method: All patients operated in the assigned period were
                                                                           enrolled in the study. A total of 105 consecutive patients for
Arun Singh                                                                 cataract surgery, (92) phacoemulsication (13) ECCE,
                                                                           received subtenon’s or peribulbar anesthesia using a mixture
Learning Objectives: At the conclusion of this presentation,               of 2% lidocaine + 0.5% bupivacaine and 90IU of
participants will be able to:                                              hyaluronidase which comprises the study size. Pain during
   •      Describe basic principles of FA and ICG                          administration and during surgical procedure, ocular
   •      Identify appropriate indications for these techniques            movements, and complications were evaluated. Epiinfo was
   •      Review diagnostic features of some specific entities             used for the analysis.
There have been impressive advances in ocular imaging during               Results: There was no statistical difference in eye movement
the past few years, with digital imaging, wide-angle photography,          between the two groups (95% CI= .79 - 1.22 , 2 tailed P-
optical coherence tomography, and high-resolution                          value =0.86) at significance level p<.05. However, the
ultrasonography being just a few examples of such progress.                subtenon group experienced less discomfort/pain during
                                                                           administration of anesthesia (95% CI= 0.30 - .63, 2 tailed
Fluorescein angiography: Fluorescein angiography has limited
                                                                           P- value = 0.00002). Pain during surgery was significantly
utility in the differential diagnosis of choroidal tumors, because
                                                                           low in the subtenon group (95% CI= 0.56 – 0.84, 2 tailed
different conditions have angiographic similarities. When
                                                                           P- value = 0.00009). Subconjunctival hemorrhage was much
interpreting fluorescein aniograms, it is essential to take
                                                                           less common in patients with peribulbar group (95%CI.=
account of the tumor pigmentation, retinal pigment epithelial
                                                                           1.38 – 2.38, 2 tailed P- value = 0.00000002.
changes, and abnormalities in the overlying retina. Fluorescein
                                                                           Conclusion: Subtenon’s and peribulbar anesthesia are equally
angiography is helpful in documenting abnormalities such as
                                                                           effective in achieving akinesia, however subtenon’s anesthesia
macular edema and neovascularisation, caused by the tumor
                                                                           is better tolerated by patients during administration and
or treatment as well as in assessing the response of such
                                                                           throughout surgery. Although subconjunctival hemorrhage
pathology to therapy.                                                      as a complication is more common in subtenon anesthesia,
Indocyanine green angiography: Indocyanine green                           both techniques had no serious complications in our study.
angiography allows better visualization of the tumor vasculature
than fluorescein angiography because of several physico-
chemical properties of indocyanine green (ICG). There are                  Fluidics in Bimanual Phacoemulsification
technical variations in the way ICG angiography is performed
which can influence the microvasculature details observed                  G.L. Arun Kumar and S. Sivagnanam
within choroidal melanoma and overall appearance of the lesion
especially in the late phases of the angiogram. In general,                Bimanual Phaco has now been refined and standardized. This
confocal scanning laser ophthalmoscopic system such as                     technique is not only done because the incisions are smaller,
Heidelberg system offers better contrast than non confocal                 but also because the Fluidics is better than Coaxial
systems as the scattered light is eliminated in the confocal               Phacoemulsification Surgery. By separating the Irrigation and
systems. In contrast to fluorescein angiography, ICG imaging               Aspiration Lines, this technique can be done with a lesser
provides diagnostic clues differentiating melanoma, metastasis             Vacuum than can Coaxial Phaco and also the followability is
and hemangioma from each other.                                            excellent. There is always the concept of Passive Aspiration
                                                                           during the Bimanual Phaco Surgery, and this along with the
                                                                           Ultrasound Energy Modulations in the newer
                                                                           Phacoemulsification Systems reduces the Effective Ultrasound
          Session M4A – Cataract Surgery                                   Time of the Surgery. The stability of the anterior chamber is
                                                                           excellent during the entire procedure and it is also safer as the
                                                                           posterior capsule is pushed backwards. Additional gadgets like
Peribulbar versus Subtenon’s Anesthesia for                                Anterior Chamber Maintainer are not a must.
Cataract Surgery

Medhat Abdulaziz Bakr and Mohammad Elsalamony                              Consideration of Pars Plana Lensectomy versus
                                                                           Conventional Anterior Surgical Approach in
Purpose: To compare two anesthetic techniques used for cataract            Cataract Surgery
surgery with regard to four variables: (Patient’s perception of
pain during administration of anesthesia and during surgery,               Richard Forster
akinesia, and complications related to each technique).
Study Design: Prospective cohort comparative study from                    This presentation will consider indications for pars plana

                                      Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                   77
     Saudi Ophthalmology 2007
     approach in conditions such as lens subluxation, polar                  Phacoemulsification in Compromised Corneas and
     cataracts, and shallow anterior chamber with preexisting                Zonules
     corneal disease.
                                                                             Ali Al-Rajhi

     Micropulses and Burst – The Ultrasound Modes                            Phacoemulsification of difficult cataract cases, compromised
     for the Present and the Future                                          zonules and corneas is associated with increased rate of
                                                                             complications. Various techniques are reported for the
     G.L. Arun Kumar, T.S. Mohammed Sayee, R. Kalaiselvan                    management of difficult cataract cases and for avoiding
     and G. Seethapathy                                                      associated complications during Phacoemlsification.
                                                                             Methods: Various techniques of phacoemulsification in
     Aim: To analyze the effectiveness of the Burst and Micropulse           morgagnian, hypermature and brown cataract and in
     Cold Phaco Modes of the Ultrasound delivery system in                   compromised corneas (low endothelial cell count or corneal
     tackling Hard Cataracts with respect to the ultrasound time             opacities) were employed. Lensectomy with insertion of
     taken for nuclear fragmentation and emulsification in                   PCIOL in the bag of subluxated lenses was done successfully
     Phacoemulsification Surgeries.                                          with sutured CTR.
     Materials and Methods: 30 Eyes of 22 patients with                      Results: Phacoemlsification is performed in difficult cases
     Cataracts of grade 3 to 4 were chosen for this study.                   utilizing various techniques that include heavy vision elastic
     60% of the patients had grade 3 nuclear sclerosis and                   substances, chopper technique and maximum utilization of
     40% grade 4. All the surgeries were performed by a                      phaco-machines to overcome hardness of the lens nucleus
     single surgeon under peribulbar anesthesia. The Galaxy                  with good success. Good anatomical and visual outcomes
     CV I Peristaltic Cold Phacoemulsification system was                    following these procedures were obtained.
     used.The ultrasound settings had a Pulse and Micropulse                 Conclusion: Difficult cataract and lens subluxation cases
     power of 30 – 40%.The burst duration in the machine                     can be managed by Phacoemlsification with good visual and
     is preset at 480 milliseconds.The vacuum was 80–                        anatomical outcome by small cataract incision
     120mm Hg for the Burst mode. The cortex was aspirated                   (Phacoemulsification) without increased comorbidity.
     using the bimanual irrigation and aspiration system and
     the Acryfold Foldable IOL was implanted through the
     2.8mm clear corneal incision. Following surgery the                     Infections After Cataract Surgery
     patients were assessed on the 1st postoperative day, after
     1 week, 4 weeks and 3 months. The parameters included                   Richard Forster
     visual acuity, corneal striate keratopathy and anterior
     chamber reaction.                                                       This presentation will focus primarily on three areas:
     Results: The Mean Burst time for each category was                      a) The increased awareness of cataract surgery infections
     assessed separately along with the total ultrasound time.                   and evolving surgical techniques.
     All the grade 4 cataracts required a burst time of 7- 8                 b) Prophylaxis and the rationale for pre-operative, intra-
     secs, where as most grade 3 were fragmented with less                       operative, and post-operative management tailored to
     than 4 secs of Burst time. The visual acuity for most                       the surgical technique and risk factors.
     grade 3 patients was 6/9 or better from the 1st post-                   c) A review of diagnostic symptoms, and signs related to
     operative day itself. The Mean Total Ultrasound Time                        surgical technique.
     taken for Hard Cataracts (grade 3 and 4) was 13.78
     seconds. The anterior chamber reaction and Descemet‘s
     striae were minimal. 3 patients had posterior capsular                  Subclinical Late Capsular Block Syndrome
     rent and 1 patient had zonular dehiscence which were
     managed.                                                                Waleed Al-Rashed
     Conclusion: This analysis clearly shows that the Burst
     Mode and the Micropulse Cold Phaco Mode with a                          Purpose: To describe a case of late capsular block syndrome
     REDUCED ON TIME and a LONG OFF TIME is safe                             noted 7 months after phacoemulsification with intraocular
     to be used on any grade of cataract and it also reduces                 lens implantation.
     the effective Ultrasound Time producing clearer corneas                 Methods: A 50-year-old woman underwent
     and silent anterior chambers on the first postoperative                 phacoemulsification after continuous curvilinear
     day.                                                                    capsulorhexis and intraocular lens implantation in the left

78                                      Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                               Saudi Ophthalmology 2007
eye. 7 months later, the capsular bag was found to be                      •  Describe epidemiology, incidence and mortality with
distended and the posterior capsule was vaulted posteriorly                   conjunctival tumors
and had flecks opacification.                                              • Identify clinical features of various benign and
Results: The distended opacified posterior capsule was                        malignant conjunctival tumors
deflated and cleared following (Nd:YAG) capsulotomy of                     • Review currently used methods for treatment of
the posterior capsule.                                                        common conjunctival tumors
Conclusion: It is important to understand the nature of this            Most conjunctival tumors are epithelial or melanocytic
syndrome to prevent complications and to avoid                          in origin. Most of the other tumors are of various
unacceptable management.                                                elements of the conjunctival stroma and include
                                                                        vascular, fibrous, neural, histiocytic, myogenic, myxoid,
                                                                        lipomatous, and lymphoproliferative tumors. Squamous
Capsular Phimosis with complete Occlusion of the                        cell carcinoma (SCC) is the most common malignant
Anterior Capsular Opening After Intact Capsulorrhexis                   tumor and its management is summarized. Although
                                                                        SCC of the conjunctiva is often considered a low-grade
M. Obailan and S. Kharashi                                              carcinoma, timely diagnosis and appropriate
                                                                        management is essential to preventing visual disability,
Shrinkage and whitening of the anterior capsule opening –               disfigurement, and life-threatening invasive disease.
capsular contraction syndrome, is a well known complication             Management is influenced primarily by the extent of
after continuous curvilinear capsulorhexis. A 72 year-old               the lesion. Surgical excision with 2 to 3 mm margins
woman underwent continuous curvilinear capsulorhexis,                   has been the preferred approach for less than 4 clock
phacoemulsification, and implantation of posterior chamber              hours of limbal conjunctival involvement. Alcohol
intraocular lens with polymethylmethacrylate haptics. Four              epitheliectomy of any corneal component is generally
months postoperatively, the patient reported a deterioration            followed by removal of conjunctival component via
in visual acuity as a result of the complete occlusion of the           lamellar scleral resection. Application of intraoperative
anterior capsular opening by fibrotic tissue. The fibrous               supplemental cryotherapy (double freeze-thaw cycles)
membrane was excised surgically in capsulorhexis fashion                to conjunctival margins reduces the risk of tumor
and sent to histopathology for analysis.                                recurrence. Topical chemotherapy has been advocated
                                                                        both intraoperatively and postoperatively as an adjuvant
                                                                        for incomplete excision of large and diffuse primary or
   Session M4B – Imaging in Ophthalmology                               recurrent tumors. More recently, topical therapy has
                                                                        been explored as an alternative to excision in selected
                                                                        cases. It has also been reported to be effective as a
Eye and Orbit MRI: Normal Anatomy                                       neoadjuvant therapy. While mitomycin-C is the best-
                                                                        studied of the chemotherapeutic agents, other topical
Claude Jacquemin                                                        agents including 5-fluorouracil and interferon alpha-2b
                                                                        have been investigated.
How to perform an MRI study . T1 and T2 images of orbital
structures. Incidences, and additional images that are
required for assesment of normal and pathological orbital               MRI and Stroke: Recent Advances
                                                                        Claude Jacquemin

Management of Conjunctival Tumors                                       Presentation of classic MRI sequences used to image
                                                                        Central Nervous system. Introduction to newer sequences
Arun Singh                                                              ,that allow a much earlier diagnose of stroke and allow the
                                                                        use of thrombolytic agents . Presentation of currently used
Learning Objectives: At the conclusion of this presentation,            imaging protocol at the Centre Hospitalier de Calais
participants will be able to:                                           [France].

                                   Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                             79
     Saudi Ophthalmology 2007

                     TUESDAY, MARCH 6                                        principals and clinical results of the latest generation of
                                                                             accommodative IOLs.
      Session T1A – Cataract and Refractive Surgery                          Methods: Optical performance as predicted by standard
                                                                             thin lens calculations are compared with clinical results using
                                                                             single optic accommodative IOLs. Result of the ongoing
                                                                             US FDA clinical trial of dual optic IOLs will be presented.
     An Analysis of Refractive Multifocal Intraocular
                                                                             Results: Single lens accommodative IOLs are able to produce
     Lens: A Long-Term Follow-Up                                             an average of 1.25 diopters of accommodative effect. The
                                                                             mechanism of action is not fully explained by translation of
     G. L. Arun Kumar, T .S. Mohammed Sayee, R. Kalaiselvan                  the effective lens position within the eye. Initial short term
     and G. Seethapathy                                                      clinical results with dual optic IOLs demonstrate up to 3
                                                                             diopters of accommodation.
     Purpose: To analyze the Acryfold Refractive Multifocal                  Conclusion: Accommodative IOLs hold great promise for
     Intraocular Lens (IOL), and its optical quality and long term           the reduction of spectacle dependence in pseudophakic
     follow-up                                                               patients. Early experience with dual optic IOLs suggests
     Materials and Methods: Acryfold Refractive Multifocal IOL               that restoration of near vision may be possible in distance
     has a Bifocal Design with a distance dominant center of                 corrected pseudophakia. New designs of single optic
     1.9mm; the mid zone (1.9 to 2.8mm) near dominant with                   accommodative IOLs demonstrate improved near acuity as
     a near vision add of 4.5 diopters and the remaining (2.8 to             compared to first generation accommodative IOLs.
     6.0mm) vdistance dominant. It is a hydrophilic acrylic
     foldable IOL with a 6.00mm Optic and overall length of
     12mm with a 360 degree fully square edge including the                  Spheric versus Aspheric IOLs After Phaco-
     haptics. The IOL can be injected through a 2.8mm incision.              emulsification
     The IOL was implanted in 30 patients bilaterally. The usual
     exclusion criteria was applied. Precise keratometry and                 Mohamed Hantera and Ahmed Tawfik
     biometry measurements were done. Surgeries were done by
     a single surgeon under peribulbar anesthesia. Temporal clear            Setting: Magrabi Hospital Aseer – Kingdom of Saudi Arabia.
     corneal incision with a central capsulorhexis of 5.5 mm to              Purpose: To evaluate the visual outcome between spheric
     5.75mm was done. The Multifocal IOL was placed in the                   IOL and two different types of aspheric IOLs. Methods: In
     bag. Post-operatively the patients were reviewed on the first           this prospective randomized controlled comparative
     post-operative day, 1 week, 1 month, 3 months, 6 months,                interventional study, 12 cataractous eyes of 12 patients had
     12 months and 18 months. Visual Acuity (for Distance and                uneventful phacoemulsification and were divided into 3
     Near), and Contrast sensitivity were assessed. Glare and                groups: Group A (4 eyes were implanted with Tecnis Acrylic
     Haloes were subjectively analyzed.                                      ZA9003), Group B (4 eyes were implanted with Acrysof
     Results: 80% of the patients were spectacle independent for             IQ) and Group C (4 eyes with Acrysof SA60AT).
     all distances. 12% of the patients required glasses only for            Uncorrected visual acuity (UCVA), best spectacle-corrected
     reading very small print. 8% of the patients required glasses           visual acuity (BSCVA), and contrast sensitivity and glare
     for distance & near vision. Contrast sensitivity was better             using Vectrovision (CSV-1000) were measured. Ocular
     following early surgery to the fellow eye and improved later.           higher-order aberrations were measured for a 4-mm pupil
     Glare and Haloes reduced in the later post operative period.            using OPD scan.
     Conclusion: Spectacle independence is more likely to be                 Results: At a mean of 6 months 1.2 (SD), 100% of
     achieved with the use of Multifocal IOL. Glare and Haloes               postoperative UCVA in all groups was >20/30. The BSCVA
     were not a issue with Multifocal IOLs and, if present,                  was 20/25 or better in 25% of Group A, 75% of Group B
     subsided post-operatively. The worst result if a Multifocal             and C. The mean spherical equivalent (SE) in Group A was
     IOL doesn’t work is that it behaves like a Monofocal IOL.               -0.5+- 0.2 diopters (D), in Group B -0.25+- 0.1 D and in
     Patients need to wear glasses for near vision.                          Group C -0.25+- 0.2. The mean of the medium spatial
                                                                             frequency - contrast visual acuity was 4.50 +- 0.23 in Group
                                                                             A and 5.50 +- 0.1 in both Group B and C. In the eyes with
     Accommodative IOLs: Can We Achieve Variable                             a mesopic pupil diameter of 4 mm or larger, the mean of
     Focus in a Pseudophakic Eye?                                            the wave front error was 1.132 +- 0.22 in Group A, 0.643+-
                                                                             0.21 in Group B and 0.692 +- 0.21 in Group C.
     John Vukich                                                             Conclusion: The visual quality in both Acrysof SA60AT
                                                                             and Acrysof IQ were nearly the same BUT both were better
     Purpose: This presentation will examine the optical                     than Tecnis Acrylic ZA9003.

80                                      Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                 Saudi Ophthalmology 2007
Ultrathin Foldable Intra Ocular Lens for Phaco                            different exposure times and concentrations of topical
Surgeries: A Clinical Study                                               mitomycin C (MMC) in preventing corneal haze after
                                                                          photorefractive keratectomy (PRK).
G. L. Arun Kumar, T .S. Mohammed Sayee, R .Kalaiselvan                    Methods: PRK was performed to correct -9.0D of myopia
and G. Seethapathy                                                        in 32 New Zealand rabbits and animals were divided into
                                                                          four groups: PRK plus BSS (group I), PRK plus MMC
Purpose: To analyze the Ultrasmart-Ultrathin Foldable Intra               0.02% for 2 minutes (group II), PRK plus MMC 0.02%
Ocular Lens (IOL) for Phaco surgeries and its Optical quality             for 12 seconds (group III) and PRK plus MMC 0.002% for
and long-term follow-up.                                                  1 minute (group IV). Rabbits were submitted to slit lamp
Materials and Methods: 60 Eyes of 30 patients with                        analysis and haze grading and sacrificed at 4 weeks after
Cataracts were chosen for this study. Following Phaco                     surgery for subsequent staining for alpha-smooth-muscle
Surgery, these patients were implanted with the Ultrasmart                actin (SMA) to detect myofibroblasts and DAPI to detect
Foldable IOL through a 2.8mm incision. Postoperatively,                   keratocytes. Another group of rabbits treated with 0.02%
the patients were assessed on the 1st postoperative day, after            mitomycin C were sacrificed at 6 months and the cornea
1 week, after 4 weeks, after 3 months, and were followed up               evaluated with DAPI stain to determine stromal cellularity.
to 18 months. The parameters assessed included visual acuity,             Results: Slit lamp grading showed a significant difference
centration, contrast sensitivity, and pseudo accomodative                 in haze formation between groups I and groups II, III, IV.(p
effect by Ultrasound Biomicroscopy.                                       < 0.05) There was also a statistically significant difference
Results: 12 patients were able to read N6 unaided post-                   between group I (13.9 cells/400X field ± 5.6 SD) compared
operatively with or without distance vision correction. 18                with groups II (1.2 ± 0.6), III (2.1 ± 2.2) and IV (2.6 ± 2.4)
patients required a near vision addition of +1.50 to +2.00                for cells staining with SMA (p < 0.01). There was no
diopters for continuous fine reading and for very fine work.              statistically significant difference between groups II, III and
Otherwise, they were comfortable for most of the distances                IV for cells staining with SMA. A significant reduction in
without the need of glasses. The amplitude of                             keratocyte density in the anterior stroma was noted in groups
accommodation was measured by streak retinoscopy for                      II (92.4 ± 24), groups III (108.6 ± 26), and IV (122.4 ± 30)
distance and for near vision, and was found to be around                  treated with mitomycin C compared to the control group I
1.7 to 1.8 diopters for most of the patients. Post-operatively,           (141.8 ± 28) at four weeks after surgery. The differences
on every visit, a dilated examination to look for the centration          between groups II, III, and IV were statistically significant.(p
of the IOL and posterior capsule opacification was done.                  < 0.05). At six months after surgery there remained low
The centration of the IOL was good in all the eyes up to 15               anterior stromal cell density compared with controls.
months of follow-up. In 2 eyes (3.3%) posterior capsular                  Conclusions: Prophylactic mitomycin C significantly
opacification developed post-operatively for which Nd Yag                 decreased corneal haze and myofibroblast generation at one
Capsulotomy was done. Contrast Sensitivity Testing with a                 month after PRK for high myopia in a rabbit model.
CSO Chart Projector showed that all the patients were able                Decreased haze and myofibroblast density were noted at both
to detect letters at a contrast sensitivity of 10-20% with the            high and low concentrations and with lower exposure times
Ultrathin Foldable IOLs compared to PMMA and                              at the higher concentration. Decreased keratocyte density
Hydrophilic Foldable IOLS where the patients were able to                 in the anterior stroma was noted in all groups treated with
detect at a contrast sensitivity of 40-50%.                               MMC, especially following the higher concentrations
Conclusion: The Ultrasmart-Ultrathin Foldable IOL gives                   (0.02%) with longer exposure, but the decrease in keratocyte
excellent visual rehabilitation following Phaco Surgeries and             density was less with lower concentration treatment. Even
has an edge over the presently available Foldable IOLs.                   at six months after surgery the anterior stromal keratocyte
Ultrathin Foldable IOLs were found to be excellent. The                   density is reduced. The long term effects of the diminished
contrast sensitivity was found to be excellent. This was                  keratocyte density are unknown.
mainly due to the thinness of the IOL and the aspherical
anterior surface.
                                                                          Effects of Dehydration on Corneal Tissue
                                                                          Absorption of Azithromycin
Effect of Prophylactic Mitomycin C on Corneal
Apoptosis, Cellular Proliferation, Haze, and Long-Term                    Khalid F. Tabbara
Keratocyte Density in Surface Ablation: Is It Safe?
                                                                          Background/Purpose: Several factors may influence the
Steven Wilson                                                             corneal tissue absorption of topical antibiotics. Following
                                                                          application of azithromycin 1.5% eyedrops, the level in tears
Purpose: To compare the effectiveness and side effects of                 may stay above the MIC of organisms for up to 6 hours. We

                                     Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                  81
     Saudi Ophthalmology 2007
     decided to study the corneal tissue absorption of topical                  techniques for removal of pediatric cataract including:
     azithromycin following corneal dehydration in rabbits.                     posterior polar cataract, membranous calcified cataract,
     Methods: Twenty-five New Zealand Albino rabbits weighing                   PHPV, traumatic cataract with special emphasis on selecting
     2-3 kg each were included. One eye of each rabbit was                      the proper technique according to patho-morphology of
     desiccated using a hair dryer at a temperature of 40∫C over                cataract, highlighting on: simple lens aspiration, phaco-style
     a period of 10 minutes. The other eye was left as control.                 lens aspiration, lensectomy and limited vitrectomy,
     Azithromycin 1.5% topical eyedrops were instilled in both                  endodiathermy and micro-scissor utilization for challenging
     eyes. Five rabbits were sacrificed at each of the following                PHPV cases. Management of secondary membranes and
     time points: 30 min, 3 hr, 6 hr, and 12 hr. The eyes were                  posterior capsule opacifications.
     enucleated and the corneal tissue specimens were removed
     and subjected to high-performance liquid chromatography
     (HPLC) mass spectrometry. A paired t test was used to
                                                                                Pediatric Ocular Oncology/Pathology with Clinical
     evaluate the statistical difference in corneal tissue absorptions
     of azithromycin at each time point.                                        Correlation
     Results: The mean corneal tissue level of azithromycin in
     dry eyes at 30 min was 66.3 µg/ml, at 3 hr 92.6 µg/ml, at 6                Ihab S. M. Othman
     hr 117.5 µg/ml, and at 12 hr 179.9 µg/ml. On the other
     hand, the mean corneal tissue levels of azithromycin in                    To introduce to the general ophthalmologist and
     normal eyes was 42.0 µg/ml for 30 min, 43.4 µg/ml at 3 hr,                 subspecialist a basic knowledge of pediatric ophthalmic
     43.3 µg/ml at 6 hr, and 80.0 µg/ml at 12 hr. There was                     tumors including intraocular, orbital and adnexal tumors
     evidence of an increase in corneal tissue absorption of                    with special emphasis on pathological correlation, clues for
     azithromycin over time (p <0.0001).                                        diagnosis, and management strategies.
     Conclusion: Dehydration and dryness of the cornea appear
     to significantly increase the corneal tissue uptake of
     azithromycin following the topical application at each time
     point except at the 30 min time point following application.                Session T1C – Prevention of Blindness Course
     This study demonstrates that corneas exposed to desiccation
     show statistically significant increase in azithromycin level
     compared to normal eyes. Therefore, it is presumed that
     dryness may increase the corneal tissue absorption of                      Endophthalmitis: Diagnosis and Management
     antibiotics following topical application. The study may have
     to be repeated on other types of antibiotics in order to                   Members, Vitreoretinal Division KKESH & KSU
     document the increase in corneal tissue uptake of antibiotics.
     In certain clinical situations and in patients with resistant              Intraocular inflammation (endophthalmitis) can occur due
     microbial keratitis, the use of hair dryer prior to the                    to an operation, trauma, through a filtering bleb, or as a
     application of antibiotics may help in the increase of corneal             metastatic infection. The prognosis is good if proper
     absorption of the antimicrobial agents.                                    management and intervention are instituted in time. The
                                                                                clinical features and management, as well as the possible
                                                                                masquerade of endophthalmitis, will be the aim of this
     The Controversy: Choice of Prophylactic Topical                            workshop.
     Antibiotics - Old versus New

     Richard Forster

     This presentation will consider the advantages and
                                                                                  Session T2A – Cornea and Refractive Surgery
     disadvantages of some of the newer antibiotics vs. older.

                                                                                Dry Eye and LASIK: Treatment and Prevention
     Session T1B – Pediatric Ophthalmology Courses
                                                                                Steven Wilson

     Different Surgical Techniques for Removal of                               Purpose: LASIK-induced dry eye is the most common
     Pediatric Cataract                                                         complication of LASIK surgery. The purpose of this
                                                                                presentation is to discuss prevention and treatment of
     Mustafa K. Ibrahim, FRCS, Sabry AboGhaly, FRCS                             LASIK-induced dry eye.
                                                                                Methods: A review of the literature and the author’s experience
     To present video clips with comments on different surgical                 with prevention and treatment of LASIK-induced dry eye.

82                                         Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                  Saudi Ophthalmology 2007
Results: The most significant risk factor for development of               Methods: The author will describe various surgical
LASIK-induced dry eye is preoperative dry eye symptoms                     techniques and modifications of currently used glaucoma
and signs. Pretreatment of patients prior to refractive surgery,           implants for routine and refractory pediatric and adult
with topical cyclosporine if available, is the most effective              glaucomas. Emphasis will be on minimizing common
treatment to prevent severe postoperative LASIK-induced                    postoperative complications including hypotony, tube
dry eye. Pretreatment is also critical for preoperative                    erosions, and tube-corneal related issues. Unique technique
wavefront analysis for custom corneal ablation. If                         of simultaneous AGV and BGI surgery will also be reviewed
cyclosporine A is not available, other treatments include                  for refractory glaucomas.
punctal plugs, artificial tears and ointments, and alpha omega             Results: Surgical outcomes of some of these techniques will
fatty acid dietary treatment. Cyclosporine A is highly                     be reviewed in the course.
effective in treating LASIK-induced dry eye that occurs after              Conclusions: With proper surgical planning and technique,
surgery—improving patient symptoms and signs, including                    Glaucoma Implant surgery can provide a safe and reliable
vision, even if the mechanism is thought to be mainly                      option for complicated glaucomas at high risk for failure.
neurotrophic from flap formation.
Conclusions: Prevention remains the best treatment for
LASIK-induced dry eye. The most effective treatment is                     Pediatric Preseptal Cellulitis: Experience from a
topical cyclosporine A therapy, but punctal plugs, and non-                Tertiary Eye Care Center
preserved artificial tears and dietary treatments are also
beneficial.                                                                Imtiaz A. Chaudhry, Farrukh A. Shamsi, Khalid M. Arfaj,
                                                                           Waleed Al-Rashed and Abdulrahman A. Al-Amri

Current Trends in LASIK: Wavefront, Conventional                           Purpose: Preseptal cellulitis has a typically benign course
and Next Generation Ablation Profiles                                      when treated with antibiotics, the clinical course depending
                                                                           on age of the patient, etiology and the causative organism.
John Vukich                                                                Untreated preseptal cellulitis may progress to orbital cellulitis
                                                                           with potential for vision and life-threatening complications.
Purpose: Advances in optical wavefront capture, analysis and               It is a relatively common infection and seldom requires
delivery will be presented.                                                admission to hospital and most patients are treated on an
Methods: The latest innovations in LASER technology will                   out-patient basis. We report our experience with treating
be discussed. Fourier analysis, iris registration, pupil centroid          preseptal cellulitis in children admitted to a tertiary eye care
shift, auto-calibration and variable spot size LASER delivery              center in Saudi Arabia.
will be critically examined. Future improvements under                     Methods: Medical records of children less than 16-years of
development including automated LASER epithelial removal                   age admitted to King Khaled Eye Specialist Hospital from
will be presented.                                                         1995 to 2005 for preseptal cellulitis were retrospectively
Results: The current generation of EXCIMER LASERs                          analyzed. Characteristics studied included, patient’s
continues to undergo refinement.                                           demographic, presenting symptoms and signs, predisposing
Conclusion: Advances in EXCIMER LASER technology                           factors, diagnostic studies and treatment outcome.
for the correction of refractive error have led to improvements            Results: Among the 53 children (35 male, 18 female, average
in optical quality and visual performance. Future                          age 3 years with range of 21 days to 16-years), 29 (55%)
innovations are under development.                                         had evidence of discharge, 24 (45%) showed tenderness or
                                                                           pain and 22 (41%) had blepharoptosis at their initial
                                                                           presentation. Preseptal cellulitis was associated with sinusitis
                                                                           or upper respiratory tract infection in 20 (38%) patients,
                                                                           with an infected wound due to trauma or recent ocular or
     Session T2B – Pediatric Ophthalmology                                 peri-ocular surgery in 18 (34%) patients, and with ocular
                                                                           infection (conjunctivitis or acute dacryocystitis) in 14 (26%)
                                                                           patients. Leukocytosis was found in 32 (60%) children and
Safe Surgery System for Glaucoma Implants in                               fever was present in 26 (49%) children. Computer
Children and Adults                                                        tomography scans were obtained for 20 (38%) children to
                                                                           diagnose any associated pathology. Among the 18 children
Sameer Ahmad                                                               who had blood drawn for cultures at the time of their initial
                                                                           presentation, only 1 had positive blood cultures for bacteria.
Purpose: To describe various surgical techniques using                     All patients were given systemic antibiotic therapy during
Ahmed Glaucoma Valve (AGV) and Baerveldt Glaucoma                          their hospital stay (average 4.6 days; range 1 to 11 days).
Implant (BGI) in children and adults.                                      Probing/irrigation, local abscess drainage or

                                      Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                   83
     Saudi Ophthalmology 2007
     dacryocystorhinostomy was performed for 10 (19%)                                Session T3A – Pediatric Ophthalmology
     patients. Among the 20 patients where cultures were taken,
     Staphylococcus aureus was recovered from the 10 (50%)
     specimens.                                                                Some Aspects of Amblyopia
     Conclusion: A history of antecedent upper respiratory tract
     infection, ocular infection or trauma may be present in                   Anthony Murray
     significant number of patients admitted for preseptal
     cellulitis to a tertiary eye care center in Saudi Arabia. It may          Amblyopia is the most common cause of visual impairment
     be associated with pyrexia and leucocytosis, however blood                in children, which often persists into adulthood. The
     cultures obtained may not be helpful in the identification                problems in childhood is estimated to be 1-4%. It is
     of the causative pathogen.                                                considered to be the leading cause of monocular vision loss
                                                                               in the 20 – 70 year old age group. Amblyopia is defined as
                                                                               a “decrease of visual acuity caused by pattern vision
     Ocular Pathology in the Preterm Infant, Beyond                            deprivation or abnormal binocular interaction for which no
     Retinopathy of Prematurity                                                cause can be detected by the physical examination of the
                                                                               eye and which in appropriate cases is reversible by therapeutic
     Linda Lawrence                                                            measures”. Amblyopia may be unilateral or less often
                                                                               bilateral. Some aspects of the diagnosis and management
     Objective: Determine ocular pathology in premature infants                of amblyopia will be presented.
     independent of ROP status.
     Design: A retrospective analysis was completed in two
     nonrandomized groups of infants and toddlers.                             A Randomized Controlled Trial of Unilateral
     Group 1: 22 - 29 weeks post conception (birth weights 410                 Anisometropic Amblyopia Using Occlusion Dose
     grams to 1389 grams) Group 2: 30-37 weeks post                            Monitors to Record Compliance
     conception. All patients were initially referred in the newborn
     period to a community hospital-based early intervention                   Musarat Awan, Frank A Proudlock and Irene Gottlob
     program, and subsequently to the affiliated Pediatric Vision
     Clinic for comprehensive ophthalmic evaluation with                       To investigate the effect and compliance of patching the
     intervention and follow-up through age 3.                                 good eye of children diagnosed with anisometropic
     Measurements: Of 582 children, from July 1992 – June                      amblyopia by objectively monitoring occlusion and to
     2004, 398 were born prematurely. 106 (18%) were children                  establish whether there is a correlation between dose-effect
     born less than 30 weeks post conception 292 (50%) were                    and improvement of visual function. Twenty-two newly
     born 30 - 37 weeks post conception.                                       diagnosed children aged 3-8 years (mean age 5.7 years) were
     Results: 46 of 106 children (43.4%) in group 1                            randomly allocated into three treatment groups with a
     demonstrated ocular pathology prior to age 3. 27; of these,               prescription of 6 hours (n=7), 3 hours (n=8) and 0 hours
     46 children (59%) did not have ROP yet demonstrated                       (n=7) occlusion. Patching was monitored using a thermo-
     significant ocular pathology. 66 of 292 (22.6%) in group 2                sensitive occlusion dose monitor. All patients were
     demonstrated ocular pathology prior to age 3. Diagnoses                   monitored for twelve weeks. The visual acuity was assessed
     included refractive error requiring spectacles, cortical visual           every three weeks using LogMAR visual acuity. In the 6-
     impairment, delayed visual maturation, strabismus,                        hour group, the average ODM patching time was 3.11 hours
     nystagmus, optic nerve atrophy, accommodative esotropia,                  (53.1% compliance). In the 3-hour group the average ODM
     congenital esotropia, and amblyopia.                                      patching time was 1.36 hours (41.6% compliance). The
     Discussion: Functional impairments from ocular conditions                 mean percentage visual improvement in the 6-hour group
     associated with prematurity frequently can be improved by                 was 43.80 percent, in the 3-hour group it was 69.14 percent
     appropriate interventions: surgically (ROP, and strabismus),              and 41.87 percent in the 0-hour group. The patching times
     optically (refractive errors, amblyopia, strabismus,                      did not significantly correlate with the visual improvement
     anisometropia), and using a trans-disciplinary approach to                (p=0.212) overall, especially in the longer hour group.
     the child with multiple functional impairments associated                 Conclusions: The lack of correlation of the patching time
     with cortical visual impairment, delayed visual maturation,               and visual improvement in anisometropic amblyopia is
     and low vision.                                                           suggestive that different treatment modalities should be
     Conclusion: Children born prematurely should have regular                 reconsidered compared to the earlier work of the strabismic
     ophthalmologic evaluations and intervention during the first              and mixed amblyopes showing a strong dose-effect
     3 years of life regardless of the presence of ROP because of              correlation. It may be important to separate anisometropic
     the high incidence of other ocular pathology.                             and strabismic amblyopia in studies.

84                                        Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                Saudi Ophthalmology 2007
Congenital Cataract – Controversial Aspects                              Retinal vascular tumors: Retinal vascular tumors represent
                                                                         at least four distinct clinical entities which include retinal
David Taylor                                                             capillary hemangioma, retinal cavernous hemangioma,
                                                                         retinal arteriovenous communications (Wyburn-Mason
                                                                         syndrome), and retinal vasoproliferative tumor. Retinal
•   The importance of Amblyopia                                          vascular tumors can also be considered as congenital (retinal
•   The relevance of History                                             cavernous hemangioma, retinal arteriovenous
•   Epidemiology                                                         communications [Wyburn-Mason syndrome]),
•   The relevance of Morphology                                          developmental (retinal capillary hemangioma), or acquired
•   General Assessment                                                   (retinal vasoproliferative tumor). Each of the subtypes has
•   Ocular Management                                                    characteristic clinical features and an attempt should be made
•   Complications and mis-management                                     to differentiate them because of specific systemic associations,
•   Infant IOLs                                                          treatment, and prognosis associated with them.
•   Unilateral congenital cataracts

                                                                                           Session T3C - Optometry
Diplopia after strabismus surgery

Anthony Murray                                                           Understanding the Impact of Vision Problems and
                                                                         their Impact on Learning
Post-operative diplopia may be related to strabismus
occurring before visual maturation or to strabismus occurring            Sandra Block
after visual maturation. When surgery moves an image out
of the suppression scotoma, this can result in fusion, a new             This course will review the more commonly encountered vision
suppression scotoma or diplopia. Diplopia may last minutes,              problems including eye movement disorders, accommodative
days or weeks or a lifetime. In adults diplopia occurring                problems, non-motor visual processing difficulties, confusion
after strabismus surgery may occur in those who had no                   of spatial orientation and visual motor integration problems.
diplopia pre-operatively as well as patients who had pre-                The signs and symptoms along with the diagnostic criteria will
exisiting diplopia. An approach to the evaluation and                    be presented, as well as treatment strategies.
management of these patients will be presented.

                                                                         The difference between clinical vision measures and
    Session T3B – Imaging in Ophthalmology                               functional vision measures

                                                                         Radi Hasan Al Shaban
Intraocular Vascular Tumors
                                                                         In rehabilitation, instructors of orientation and mobility for
Arun Singh                                                               the visually impaired face some difficulties during assessing
                                                                         most cases because of the ambiguity of the referral which
Learning Objectives: At the conclusion of this presentation,             does not give the exact functional measures. Therefore, good
participants will be able to:                                            clinical visual information is needed to help determine what
• Describe various types of retinal and choroidal vascular               is needed for a functional setting.
• Identify clinical features of various retinal and choroidal
    vascular tumors                                                      Assistive Technology for the Visually Impaired
• Review currently used methods for treatment of common
    retinal and choroidal vascular tumors                                Anis El-Sawy
Uveal vascular tumors: Uveal vascular tumors represent benign
hamartomatous disorders and are classified as hemangioma.                Assistive Technology could provide the visually impaired
Although the iris and ciliary body can be involved, hemangioma           access to information through reading printed text, surfing
most frequently affect the choroid. Choroidal hemangioma                 the Internet and communicating with others. It also could
can either be circumscribed or diffuse. In general, uveal                provide privacy and independence. Such assistive technology
hemangioma may be confined to the globe or be a manifestation            for the visually impaired could possibly help in education
of a widespread hemangiomatous disorder.                                 and employment leading to an improved quality of life.

                                    Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                  85
     Saudi Ophthalmology 2007
     Ocular and Systemic Problems Encountered in                                 Session T4A – Pediatric Ophthalmology Course
     Patients with Common Causes of Intellectual
     Disability and their Evaluation
                                                                                Nystagmus in Children
     Sandra Block                                                               David Taylor

     This course will review the most commonly encountered                      Describing Nystagmus
     syndromes including Down’s Syndrome, cerebral palsy and                    “Normal” Nystagmus
     Fragile X. A review of the most frequently encountered ocular                     OKN, Vestibular, Voluntary
     and systemic problems associated with these syndromes will                 Early onset Nystagmus
     be presented. The goal is to ensure that the clinician is                  EOIN
                                                                                       Waveform evolution, Waveforms, Associated
     prepared to provide optimum eye care for these patients who                       sensory abnormalities, Management, Treatment
     are known to have a high prevalence of vision problems.                    Latent Nystagmus
                                                                                Periodic Alternating Nystagmus
                                                                                See-Saw nystagmus
     Essential Components for Promoting Education of                            Neurological Nystagmus
                                                                                       Vertical Nystagmus, Acquired Pendular, Nystagmus,
     Persons with Low Vision                                                           Convergence-retraction
                                                                                Saccade abnormalities
     Bhushan Punani                                                                      Initiation Failure (COMA), Gain disorders

     The World Health Organization and many countries have
     adopted the definition and concept of low vision. The National                  Session T4B - Imaging in Ophthalmology
     Legislations of many countries have also adopted the definition
     of low vision. Many countries still do not differentiate between           Uveal Tumors: Differential Diagnosis and Managment
     low vision and blindness. In many Schools For The Blind,
     there are some with useful vision. It is estimated that there are          Arun Singh
     four times as many people with low vision as compared to
     the number of blind people. Many such children need surgical               Learning Objectives: At the conclusion of this presentation,
     or refractive services to improve their vision, and others need            participants will be able to:
     low vision care. In some cases, they have been regarded as                 •           Identify clinical features of uveal melanoma
     backward or mentally handicapped, as they can, for example,                •           Become aware of some unusual ocular tumors
     only read slowly and are not able to copy from the blackboard              •           Review currently used diagnostic methods
     due to their limited vision. There is a great need to develop              Achieving a correct diagnosis in a patient with a possible uveal
     appropriate services for people with low vision, especially                tumor can be difficult. Several hemorrhagic processes can simulate
     children, as it is important to encourage them to use the vision           a melanoma, including a macular disciform, extramacular
     they have, in addition they need to be taught how to interpret             disciform, subretinal hemorrhage, or an arterial macroaneurysm.
     the little and sometimes incomplete visual information they                A choroidal hemangioma is a benign simulating lesion. The
     get. Once a child has been identified as having low vision,                pattern clinically, on fluorescein angiography, ICG, and
     information from a functional assessment can be very helpful               ultrasound is characteristic. Choroidal metastases, usually occur
     to ophthalmic staff when prescribing the type of magnifying                in the posterior pole. They are amelanotic and almost never
     device for the child. Therefore, functional assessment should              produce a collar button-shaped configuration. Unlike a choroidal
     come before a thorough clinical assessment, if a person has                melanoma, on ultrasound these lesions have medium to high
     been identified with irrevocably low vision.                               reflectivity. Scleritis may also mimic a choroidal melanoma.

     Amblyopia – Current Trends in Treatment                                             Session T4C – Optometry Workshop
     Sandra Block                                                               Techniques to Treat Soft Binocular Vision Problems
                                                                                in Primary Care Practice (Workshop)
     A review of the types of amblyopia will be presented along
     with appropriate diagnostic criteria. The latest research on the           Sandra Block
     treatment of amblyopia will be presented which includes types
     of interventions. The recommended treatments for amblyopia                 This workshop will present several techniques to treat
     have changed in recent years and new guidelines which include              accommodative and vergence problems which frequently occur
     considerations for the amount and type of occlusion as well as             in pediatric patients. The techniques presented can be easily
     integration of active treatment.                                           integrated to any practice.

86                                         Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                  Saudi Ophthalmology 2007

              WEDNESDAY, MARCH 7                                           that stromal surface irregularity after PRK for high myopia
                                                                           results in defective basement membrane regeneration and
         Session W1A – Refractive Surgery                                  increasebepithelium-derived TGFb signaling to the stroma
                                                                           that increases myofibroblast generation.

Surface Irregularity and the Cellular Mechanism of
Haze Formation After Surface Ablation Procedures                           Toric Posterior Chamber Phakic Lenses for the
                                                                           Correction of Compound Myopic Astigmatism
Steven Wilson                                                              After Deep Lamellar Keratoplasty

Purpose: To determine the role of surface irregularity and                 Mohamed Alaa El Danasoury
basement membrane defects in haze formation after PRK
and other surface ablation procedures.                                     Purpose: To assess the efficacy, predictability, and safety of
Methods: A fine mesh screen was used to mask excimer laser                 toric posterior chamber phakic lenses (Toric ICL) for
ablation using a refractive ablation of -4.5 diopters (D) by               correction of residual compound myopic astigmatism after
placing the screen for varying percentages of pulses at the                deep lamellar keratoplasty (DLKP). Setting: Magrabi Eye
end of the ablation in 108 New Zealand rabbits, divided                    & Ear Hospital, Jeddah
into eight different groups: -4.5 D PRK with no screening                  Methods: Fourteen eyes of 14 patients with previous DLKP
(group I), -4.5 D PRK with screening of 10% of pulses                      were enrolled in a prospective study. Inclusion criteria
(group II), -4.5 D PRK with screening of 30% of pulses                     included a history of DLKP before 16 months or more for
(group III), -4.5 D PRK with screening of 50% of pulses                    correction of keratoconus, stable manifest refraction for at
(group IV), -4.5 D PRK with screening of 50% of pulses                     least 3 months after removal of all corneal sutures, spherical
followed by phototherapeutic keratectomy (PTK)-                            equivalent refraction (SE) between -5.00 and -16.00 D,
smoothing using 1% methylcellulose as masking agents                       spectacle-corrected visual acuity of 20/40 or better, and
(group V), -9.0 D PRK, -9.0 D PRK followed by PTK-                         endothelial cell count above 2200 cell/mm2. Each eye
smoothing, and unwounded controls. Slit lamp analysis and                  received a myopic toric ICL through a 3 mm temporal clear
haze grading was performed in all eight groups. Rabbits were               corneal incision under topical anesthesia.
sacrificed at 4 hours or 4 weeks after treatment and corneas               Results: At baseline; mean SE refraction was -9.35 ± 2.64
underwent immunohistological staining for myofibroblast                    D (range; -5.25 to -15.75 D), 7 eyes (50%) could see 20/20
marker alpha-smooth muscle actin (SMA) and a4.                             or better with correction. At 12 months, (follow-up rate,
Results: Slit-lamp grading revealed severe haze formation in               85.7%), SE refraction was -0.28 ± 0.45 D (range; -1.25 to
corneas in groups IV and VI, with significantly less haze in               0.50 D), uncorrected visual acuity was 20/40 or better in
groups II, III, and VII and insignificant haze compared with               10 eyes (83.3%) and 20/20 or better in 7 eyes (58.3%); 3
the unwounded control in groups I and V. Analysis of SMA                   eyes (25%) gained 2 or more lines of spectacle-corrected
staining at 4 weeks after surgery, the approximate peak of haze            visual acuity. Mean endothelial cell loss was 2.3%.
formation in rabbits, revealed low myofibroblast formation in              Conclusion: Toric ICL implantation is effective, predictable,
group I (1.2 ± 0.2 cells/400x field) and group V (1.8 ± 0.4),              and relatively safe for the correction of the residual
with significantly more in groups II (3.5 ± 1.8), III (6.8 ±†1.6),         compound myopic astigmatism after DLKP.
VII (7.9 ± 3.8), IV (12.4 ± 4.2) and VI (14.6 ± 5.1). The
screened groups were significantly different from each other (p
< 0.05), with myofibroblast generation increasing with higher              Next Generation Anterior Segment Imaging with
surface irregularity in the –4.5 diopter PRK groups. The –9.0              the Visante OCT
diopter PRK group (VI) had significantly more myofibroblast
generation than the –9.0 diopter PRK with PTK-smoothing                    John Vukich
group (VII) (p <0.01). Areas of basement membrane disruption
were demonstrated by staining corneas for integrin a4 and were             Purpose: Optical Coherence Tomography (OCT) imaging
prominent in corneas with grade I or higher haze. SMA-positive             of the anterior segment of the eye has been developed as a
myofibroblasts tended to be present sub-adjacent to basement               diagnostic tool. This paper will examine the potential use
membrane defects.                                                          of this information in patients with a variety of ophthalmic
Conclusions: These results demonstrated a relationship                     conditions.
between the level of corneal haze formation after PRK and                  Methods: OCT images of patients following LASIK
the level of stromal surface irregularity. Basement membrane               refractive surgery were examined to determine the ability to
abnormalities are noted in corneas with prominent                          measure flap and residual corneal bed thickness. Pre-
myofibroblast generation and haze formation. We hypothesize                operative images were compared to Orbscan and ultrasound

                                      Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                87
     Saudi Ophthalmology 2007
     pachymetry readings. Patients with narrow angle glaucoma,               associated with much less intrastromal cell death and
     as well as other ocular diseases were examined by OCT.                  inflammatory cell infiltration, and, therefore, a diminished
     Results: OCT images were able to identify the flap and                  wound healing response, compared to the 15 kHz model I
     residual corneal bed thickness up to 6 months following                 Intralase femtosecond laser. The side cut through the epithelium
     LASIK surgery. Pachymetry measurements correlate well                   contributes to increased intrastromal keratocyte death and
     with both Orbscan and ultrasonic readings. Detailed images              inflammatory cell infiltration. Minimizing side cut energy and
     of anterior chamber anatomy including virtual gonioscopy                lamellar cut energy decreased inflammation and the wound
     of the angle anatomy are possible with OCT.                             healing responses associated with the femtosecond laser because
     Conclusion: OCT provides an accurate and repeatable                     the level of keratocyte necrosis is markedly reduced.
     representation of the anterior segment of the eye. Images
     are capable of providing detailed analysis of the corneal
     anatomy following LASIK as well as assessment of the angle              Topography-Based Custom Ablation Treatment for
     anatomy in glaucoma patients.                                           Difficult Cases of Primary Asymmetric or Irregular
     Femtosecond LASIK flaps: The Importance of                              Amgad Mostafa Dowidar
     Optimizing Energy Levels
                                                                             Purpose: Topography-based Custom Ablation Treatment (T-
     Steven Wilson                                                           CAT) is a well known procedure for optical zone enlargement
                                                                             after various refractive surgeries as well as for centration of
     Purpose: To evaluate stromal cell death and immune cell                 decentered ablations. However, it can be of a great value in
     infiltration with the femtosecond laser (Intralase) and to              some selected primary cases to deal with asymmetric and/or
     determine the effect of the side cut on stromal cell death              irregular astigmatism.
     and immune cell infiltration.                                           Methods: 24 eyes were operated upon using Eye-Q
     Methods: Rabbits were anesthetized and underwent flap                   Wavelight ALLEGRETTO system by means of T-CAT and
     formation (9 mm diameter and 100 micrometer thickness)                  getting the corneal topographic data from ALLEGRO
     with either the 15 kHz, 30 kHz or 60 kHz femtosecond                    Topolyzer. All eyes were followed up at 3 months or more.
     laser (Intralase, Irvine, CA) (110 µm thickness, 9.0 mm                 Results: More than one line improvement in BSCVA was
     diameter, 0.9 uJ to 1.5 uJ raster stromal energy, 0.9 uJ to             attained in 30% of eyes. None of the treated eyes lost any
     1.5 uJ side-cut energy). A control group had flaps performed            line of BSCVA.
     with the Hansatome microkeratome. A second group of                     Conclusion: Perhaps corneal aberrations are best treated by
     corneas had intrastromal ablation without the transepithelial           corneal or topography-guided procedures. T-CAT
     side cut. Corneas were removed at 24 hours after surgery                rehabilitates difficult corneas with reasonable expectations.
     and evaluated for stromal cell apoptosis with the TUNEL
     assay and monocyte infiltration detected by
     immunocytochemistry for CD11b. Electron microscopy was                  Comparison of LASIK Using Conventional versus
     performed to determine the mode of cell death.                          Optimized Ablation Profile
     Results: After complete flap formation, intrastromal cell
     death was markedly reduced (P<0.01) with the 60 KHz and                 Mohamed Alaa El Danasoury
     30kHz lasers compared with the 15 kHz laser. Corneas that
     had intrastromal cut alone with the 60 kHz and 30 kHz                   Purpose: To compare conventional LASIK ablation with a
     femtosecond laser had markedly reduced stromal cell death               new Optimized Prolate Ablation algorithm (OPA) intended
     compared to the 15 kHz laser. Monocyte infiltration was                 to maintain corneal asphericity over the entire mesopic pupil.
     also significantly greater in corneas that had both the                 Setting: Magrabi Eye & Ear Hospital- Jeddah
     intrastromal and side cut compared to corneas with no side              Methods: Eighteen eyes of 9 patients received LASIK to
     cut. Reducing the lamellar and side-cut energy to the                   correct compound myopic astigmatism in a bilateral,
     minimum possible for the individual laser reduced                       prospective, randomized clinical trial. Inclusion criteria
     intrastromal inflammatory cell infiltration. The 60 kHz laser           included spectacle-corrected of 20/20 and baseline spherical
     that delivered the lowest total energy level had similar cell           equivalent refraction (SE) between -3.00 and -9.00 D. Each
     death and inflammation to the microkeratome-treated                     patient received conventional ablation on one eye
     group. Stromal cell death triggered by the femtosecond laser            (conventional group) and OPA ablation on the other (OPA
     was primarily necrosis, in contrast to the microkeratome                group). Ablation profile assigned to each eye was
     where cell death was primarily necrosis.                                randomized. Nidek CXIII excimer laser and Intralase
     Conclusions: The 30 kHz and 60 kHz femtosecond lasers are               femtosecond laser were used for all eyes. In OPA treatment,

88                                      Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                Saudi Ophthalmology 2007
corneal topography and wavefront measurements were used                  Hilgartner first used external beam radiotherapy in 1903.
to individualize ablation profile calculations with case-                Kupfer used chemotherapy in 1953 for the treatment of
specific asymmetric compensation for peripheral laser energy             retinoblastoma. Reese and Ellsworth proposed a
loss.                                                                    classification for retinoblastoma that has guided the
Results: Preoperative mean SE refraction was -5.06 D and -               treatment for the last 50 years.
5.43 D in OPA and conventional groups respectively; there                   In recent years there has been a trend away from
was no statistically significant difference in mesopic pupil             enucleation, with the increased use of alternative globe
diameter, pachymetry, corneal asphericity (Q value) and                  conserving methods of treatment including, laser
corneal spherical high order aberrations. Average follow-up              photocoagulation,          cryotherapy,        transpupillary
was 6.7 months. Postoperative mean SE was 0.12 D and -                   thermotherapy, plaque radiotherapy external beam
0.02 D, mean corneal spherical aberration was 0.29 µ and                 radiotherapy, and chemotherapy. The decision making
0.53 µ (p<0.05) and mean Q was -0.25 and 0.21 (p<0.05)                   process for treatment of retinoblastoma is rather complex as
for OPA and conventional groups respectively. Seven eyes                 several factors such a family history, status of the other eye,
(78%) in each group saw 20/20 or better uncorrected, no                  number size and location of tumors, and the visual potential
eyes lost 2 or more lines of spectacle-corrected visual acuity.          are important considerations. In general, advanced unilateral
Conclusion: OPA ablation profile preserves corneal                       disease is best managed by enucleation with continued
asphericity over the entire mesopic pupil and induces less               monitoring of the uninvolved eye. Treatment of bilateral
corneal spherical aberrations compared to conventional                   disease is initiated by chemotherapy (chemoreduction) with
ablation after myopic LASIK. Longer follow-up and larger                 local therapy comprising of cryotherapy, thermotherapy or
series are needed.                                                       brachytherapy. External beam radiation therapy as an initial
                                                                         treatment for bilateral disease is generally not recommended.

Updates of Multifocal Ablations in PresbyLASIK

Mounir A. Khalifa                                                                   Session W1C, W2C, W3C and W4C
                                                                                       – Pediatric Low Vision Course
Correcting presbyopia was the major concern of refractive
surgeons for the past few years. Different patterns of
multifocal ablations are available now for clinical use from             Pediatric Low Vision Course
many excimer laser companies. All are trying to give the
best UCVA and best DCNA, without significant reduction                   Linda Lawrence, Sarfaraz Khan and Bhushan Punani
in the contrast sensitivity. Examples of these patterns will
be presented with the correlation of the optical design to               Objectives:
the comparable multifocal IOL. Clinical studies on some                       1. Review typical visual development in the child.
cases will also be presented.                                                 2. Learn how to perform comprehensive functional
                                                                                  visual assessment used for children with low
                                                                              3. Determine appropriate interventions including
Session W1B – Retinoblastoma Course                                               optical devices.
                                                                              4. Learn examination techniques specific for
                                                                                  children with multiple disabilities.
Management of Retinoblastoma                                             Goals and objectives will be met through didactic lectures
                                                                         and hands on use of methods to test visual acuity, perform
Arun Singh                                                               functional visual assessment, and intervene through use of
                                                                         optical devices.
Learning Objectives: At the conclusion of this presentation,             Course Outline:
participants will be able to:                                                 1. Review typical visual development in the child.
     • Describe epidemiology, incidence, mortality, and                       2. Learn how to perform comprehensive functional
         genetics of retinoblastoma                                               visual assessment used for children with low
     • Identify clinical features of retinoblastoma                               vision.
     • Review currently used methods for treatment of                         3. Measuring visual acuity multiple methods which
         retinoblastoma                                                           are taught and can be used according to age and
Enucleation with removal of a long stump of optic nerve as                        ability.
treatment was recommend by Von Graefe in 1884 and                             4. Functional Visual Assessment, ocular motility,

                                    Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                 89
     Saudi Ophthalmology 2007
             accommodation and convergence, visual fields,                    included in the study. Thirty-seven patients with corneal ectasia
             color.                                                           after LASIK were referred from other refractive centers in Saudi
         5. What is an eye exam by an Ophthalmologist.                        Arabia. The patients underwent LASIK by 14 different
         6. Basic eye pathology: How does diagnosis affect                    ophthalmologists at 8 centers. One hundred eleven patients
             intervention strategies?                                         who had successful LASIK procedures during the same period
         7. Interventions: medical, surgical, optical, non-                   at The Eye Center were age and gender-matched and served as
             optical, trans-disciplinary team, educational.                   controls. An attempt was made in each case to leave a residual
         8. Recording findings: Development of documents.                     stromal bed of 250 µm. Corneal topographic analysis was made
         9. Utilizing findings in the individual educational                  on every patient. The follow-up period ranged between 2 and
             and life plan.                                                   5 years with a mean follow-up period of 3.6 years. There was
         10. Appropriate follow-up of child.                                  no statistically significant difference in the follow-up period
         11. Education of Children with Visual Impairment.                    between patients who had corneal ectasia and patients who
                                                                              had LASIK without ectasia. The main outcome measures
                                                                              included corneal keratometry, oblique cylinder, pachymetry,
      Session W2A – Cornea and Refractive Surgery                             posterior surface elevation, difference between the interior and
                                                                              superior corneal diopteric power, and posterior best sphere fit
                                                                              (BSF) over the anterior BSF. Each parameter was given a grade
     Preventing and Managing LASIK-Induced Ectasia                            of 1 to 3, and an ectasia score was established.
                                                                              Results: Patients who had a grade of 7 or less showed no
     Steven Wilson                                                            evidence of corneal ectasia, whereas 16 (59%) of 27 patients
                                                                              who had a grade of 8 to 12 had corneal ectasia. Twenty-one
                                                                              (100%) of 21 patients with a grade of more than 12 had
     Purpose: Ectasia associated with progressive irregular
                                                                              corneal ectasia after LASIK (p<0.0001).
     astigmatism and myopia is a relatively rare but serious
                                                                              Conclusion: There is a grey line between normal and abnormal
     complication of LASIK. The purpose of this presentation is
                                                                              corneas. The proposed scoring system may serve as a guideline
     to discuss prevention and treatment of LASIK-induced ectasia.            for identification of patients who are at risk of developing
     Methods: A review of the literature and the author’s                     corneal ectasia after LASIK. The scoring system, however, does
     experience with prevention and treatment of ectasia.                     not replace a comprehensive eye examination. This study
     Results: The most significant risk factors for ectasia include           represents a retrospective analysis of data of patients with
     forme fruste keratoconus on corneal topotraphy, high                     corneal ectasia after LASIK and has shown that the risk score
     myopia, low corneal thickness, low residual posterior stromal            may help in the identification of patients who are at high risk
     bed and multiple enhancements. Exclusion of early                        of corneal ectasia after LASIK. This risk factor, however, may
     keratoconus and pellucid marginal degeneration is critical.              be irrelevant in patients undergoing surface ablation.
     If there is any concern whatsoever that the topographic
     pattern represents forme fruste keratoconus, then surface
     ablation should be considered. In cases where extasia occurs,            Corneal Collagen Cross-Linking for Stabilization of
     treatment options include rigid contact lenses, Intacs, and              Keratoconus
     corneal transplantation. UV-crosslinking remains a
     controversial treatment with uncertain benefit.                          Mohamed Alaa El Danasoury
     Conclusions: Prevention remains the best treatment for
     LASIK-induced ectasia. Most cases can be eliminated by                   Purpose: To assess safety, efficacy, stability and corneal
     careful avoidance of forme fruste keratoconus topography,                changes after corneal collagen cross-linking using riboflavin
     low corneal thickness, and low residual stromal bed. Use                 and a prototype UV device.
     surface ablation whenever there is uncertainty, although the             Methods: 12 eyes of 12 patients with keratoconus received
     risk of ectasia is not eliminated by surface ablation.                   corneal cross-linking with riboflavin and a UV device (IROC
                                                                              – Zurich, Switzerland). All patients had bilateral progressive
                                                                              keratoconus as documented by topography; treatment was
     Grading System for Corneal Ectasia Following LASIK                       performed on the more advanced eyes. Riboflavin 0.1% in
                                                                              dextrane 20% was applied for 15 minutes after mechanical
     Khalid F. Tabbara                                                        removal of the epithelium, UVA light (wave length 370 nm,
                                                                              fluence; 3.4 mJ/cm2) was focused on the cornea for 30 minutes.
     Purpose: The main purpose of this study is to propose a                  Results: 7 eyes (58%) completed the 6 month examination.
     risk score that may help in the prediction of patients who               All corneas were clear, no eyes lost 2 or more lines of spectacle
     are at risk of developing corneal ectasia following LASIK.               corrected visual acuity. No significant change on corneal
     Patients and Methods: A total of 148 consecutive patients were           topography was noted except on one cornea that showed

90                                       Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                  Saudi Ophthalmology 2007
2.00 D of flattening. No signs of progression of keratoconus               to clarify whether the ultrastructure changes coincide with
were observed.                                                             the clinical topographical features or not.
Conclusion: Corneal collagen cross linking in keratoconus eyes             Methods: Five keratoconus corneas and one normal human
is safe and effective over a 6 months period. Efficacy, stability          cornea were investigated. A cell maceration method in
and long-term safety needs longer follow-up to be proven.                  combination with scanning electron microscopy (SEM) was
                                                                           used to examine the collagen orientation in the apical and
                                                                           para-apical regions of corneas.
Ferrara Intrastromal Ring Segments For Correction                          Results: In normal corneas, the typical morphologic
of Primary Ectatic Corneal Disorders                                       appearance of honeycomb-like fibrillar structure of
                                                                           Bowman’s layer on SEM was found. In contrast, ruptures
                                                                           were not only found at the apical cone, but also were found
Mohamed Hantera, Wesam Badawi and Mohamed Alaa El
                                                                           beyond the central apex in more peripheral areas within the
                                                                           optical zone, and the severity of the rupture does not correlate
                                                                           with disease severity clinically. This was especially true in
Purpose: To assess the outcome of Ferrara intracorneal ring                advanced stages of the disease.
segments for keratoconus.                                                  Conclusion: From cases in which preoperative topographic
Setting: Magrabi Hospital Aseer, Khamis Mushayet, Saudi                    data were available, it was found that topographical features
Arabia.                                                                    alone failed to indicate the full extent of the progress of
Methods: In this retrospective non-comparative                             keratoconus towards the corneal periphery. Moreover, in
interventional case series, 15 eyes with primary ectatic                   addition to profound changes seen in the central zone of
corneal disorders (keratoconus and pellucid marginal                       the cornea that presumably contribute to the apex of the
degeneration) of 11 patients that had Ferrara intracorneal                 cone, tissue changes and ruptures in Bowman’s layer were
ring segment implantation were reviewed. Uncorrected visual                also found at the corneal periphery. A clear link between
acuity (UCVA), best spectacle-corrected visual acuity                      the severity of the disease clinically, and the extent of the
(BSCVA), central corneal curvature, corneal astigmatism,                   Bowman’s breaks was not apparent here, suggesting perhaps
surface regularity index, surface asymmetry index, and                     that events deeper in the stroma have a significant influence
complications were analyzed.                                               on the tissue changes seen in keratoconus.
Results: At a mean follow-up of 6.0 months +/- 2.5 (SD),
the BSCVA improved in 46% of eyes, was unchanged in
40%, and worsened in 14 %. The UCVA improved in 93%
of eyes, was unchanged in 7%, and didn’t worsen in any of                  Descemet’s Stripping Automated Endothelial
the cases. The mean spherical equivalent (SE) was reduced                  Keratoplasty (DSAEK) for Pseudophakic Corneal
from -2.68 +/- 3.50 diopters (D) to -0.63+/- 1.25D and the                 Edema. Six Months Results
mean refractive astigmatism from -2.65 +/- 4.50 D to - 1.37
+/- 1.5 D. The mean central corneal curvature was reduced                  Mohamed Alaa El Danasoury
from 45.6+/- 5.3D to 42.7 +/- 3.1 D. Eyes with central
keratoconus (Type I and II) had statistically significantly                Purpose: To assess efficacy, reproducibility, and safety of
better results than eyes with inferior keratoconus (Type III               DSAEK for surgical treatment of pseudophakic corneal edema.
and IV) in topographic astigmatism, SE, and refraction                     Methods: 12 eyes with pseudophakic corneal edema received
cylinder. Penetrating keratoplasty was avoided in all the eyes             DSAEK in a prospective non-comparative case series.
(100%) during the follow-up. Intracorneal ring segment                     Recipient Descemet’s membrane and endothelium were
decentration occurred in 3 eyes (20%), segment extrusion
                                                                           stripped with a microhook, and an 8 mm posterior lamellar
in one eye (6%) , and night glare in all eyes (100%).
                                                                           graft was introduced through a 4.5 mm sclero-corneal incision.
Conclusion: Implantation of Ferrara intracorneal ring
segments in patients with ecstatic corneal disorders was a                 Donor disc was secured in place with a large air bubble; no
safe and reversible procedure that led to stable results and               sutures were used to fix the graft. Artificial chamber and
avoided or delayed PKP in many cases.                                      microkeratome were used for donor lamellar dissection. Hanna
                                                                           trephine was used to punch the donor disc.
                                                                           Results: Mean donor disc thickness was 197 ± 41.4 µm. At 6
Microscopical Study of Bowman’s Layer Changes in                           months (follow-up 91.6%), all corneas were clear; mean
Human Keratoconus Corneas                                                  astigmatism was 2.7 ± 2.1 D, 8 eyes (72.7%) saw 20/60 or
                                                                           better with correction. Complications included pupillary block
Abdullah Ali Assiri, Rob Young, Andrew Quantock and                        in 1 eye (8.3%) relieved by drainage of air through a
Keith Meek                                                                 paracentesis and early disc displacement in 2 eyes (16.6%)
                                                                           managed by disc repositioning on the third day after operation.
Purpose: To investigate the 3-dimensional collagen fibril                  Conclusion: DSAEK is effective, reproducible and relatively safe
organization in the Bowman’s layer of keratoconus corneas                  in treating pseudophakic corneal edema. To evaluate Descemet’s

                                      Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                  91
     Saudi Ophthalmology 2007
     stripping endothelial automated keratoplasty, a technique that
                                                                                        Session W3B – Pediatric Opthalmology
     potentially offers many advantages compared to the currently
     used penetrating keratoplasty including rapid healing and absence
     of suture- related complications. Posterior lamellar keratoplasty
     with stripping of Descemet’s membrane and introduction of
                                                                                 Aspects of the Congenital Cranial Disinervation Disorders
     donor disc through small incision (DSEAK) enables the
     replacement of the diseased endothelium with healthy donor                  Anthony Murray
     disc including endothelium, Descemet’s membrane and a thin
     layer of posterior stroma through a small corneo-scleral wound.             Strabismus syndromes, now known as the congenital cranial
     It has the advantage of rapid rehabilitation with the absence of            disinervation disorders (CCDDs), are characterized by
     potential complications related to sutures and wound healing                abnormal movements of the eyes, eyelids, face or a combination
     associated with conventional penetrating keratoplasty.                      of these. They include congenital fibrosis of the extraocular
                                                                                 muscles (CFEOM), Duane retraction syndrome (DURS),
                                                                                 congenital horizontal gaze palsy with scoliosis (HGPS),
                                                                                 congenital facial palsy (CFP), Mˆebius Syndrome and
     LASIK versus Surface Ablation for the Correction
                                                                                 Congenital Ptosis. The term congenital cranial disinervation
     of Myopia Using Nidek and Visix                                             disorders reflects the concept that these disorders result from
                                                                                 developmental errors in inervation of the ocular and facial
     Faisal Ghadfan                                                              muscles and not from primary dysfunction of the muscles
                                                                                 themselves. Some aspects of these conditions will be presented.
     Purpose: To study the visual and refractive outcomes of laser
     in situ keratomileusis (Lasik) versus surface ablation for the
     correction of myopia at King Khaled Eye Specialist Hospital                 Developmental Abnormalities of the Cornea and
     utilizing two different machines.                                           the Genes that Cause Them
     Methods: A total of 1024 eyes of 540 patients ( 267 male, 273
     female), with a mean age of 30 years (range 16-75 years)                    David Taylor
     underwent Lasik procedures (699 eyes) and surface ablation
     (92 PRK, 95 Transepithelial PRK(TPRK), 168 Lasek) for                       1.    Imaging the developing visual system
     correction of myopia using Nidek EC 500, and Visx star S3                   2.    Retinal Ganglion Cell Development
     Machines. Outcome measures were visual and refractive results.              3.    Fetal Fissure-related development & abnormalities
     Results: Preoperatively, the mean spherical equivalent was 4.8D             4.    RGC-related abnormalities: Optic Nerve Aplasia,
     (range 0.5-10D) and the mean cylindrical power was 1.09D                          Optic Nerve Hypoplasia, Achiasmia, Optic Tract
     (range 0.25-4.25D) and the mean corneal thickness was 542                         defects
     µm (range 438-659 µm) by ultrasound and 535 µm (range 432-                  5.    Other abnormalities: Tilted Discs, Peripapillary
     682 µm) by orbscan and the difference was within 10 µm in                         Staphyloma, Morning Glory Disc Anomaly, Renal-
     50% and within ± 20µm in 80% and 80% of eyes are 5 µm                             coloboma syndrome, ‘Pedler’ coloboma,
     thinner in the orbscan compared to only 13% of eyes by                            Megalopapilla,
     ultrasound. Uncorrected visual activity was ≥ 20/20 in 43%,
     56%, 45% ≥ 20/25 69%, 71%, 66% ≥ 20/30 in 85%,
     ≥ 20/40 92%, 86%, 87% of eyes in Lasik/TPRK, PRK and                        Current Use of Adjustable Sutures for Strabismus
     Lasek respectively at final visit. Visual acuity of ≥ 20/40 was             Surgery
     92.4% in eyes without complications compared to 70.5% in
     eyes with complications following Lasik. Spherical equivalent was           Anthony Murray
     ±0.5 D in 22% versus 26%, ±1.0 D in 58.5% versus 58 % and
     within ±2.0 D in 88.5% versus 80% in Lasik and surface ablation             The goal of adjustable suture strabismus surgery is to utilize
     respectively. The visual and refractive outcome was better in Nidek         the minimum number of procedures to provide motor
     EC 500 compared to Visx S3 but was not statistically significant.           alignment and sensory improvement, by modifying the site
     Intra-operative complications was found in 19 cases (2.8%), 13              of muscle insertion in the immediate post-operative period.
     incomplete flap, 6 button holes and 1 complete flap. The                    Adjustable sutures can be used in almost all adult patients
     postoperative complications were found in 4.93% (Lasik), 17.4%              and should be considered in selected children who have had
     (PRK) mostly grade 1-4 haze.                                                multiple previous operations or who have unpredictable
     Conclusion: There is a tendency of obtaining better visual                  mechanical factors. This workshop will discuss an approach
     outcome following Lasik compared to surface ablation and                    to evaluating patients for adjustable suture surgery, suture use,
     more in Nidek compared to Visx but was not statistically                    end points and current techniques of conjunctival and muscle
     significant. Eyes without complications had better outcome.                 adjustment.

92                                          Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                 Saudi Ophthalmology 2007

                                                   Poster Abstracts

Outcome of Primary Penetrating Pediatric Keratoplasty                     of pterygium excision result to scleral melting. Therefore
                                                                          barring of sclera after one month of pterygium excision and
Ali Al-Ghamdi, Ali Al-Rajhi and Michael D. Wagoner                        topical mitomycin-C 0.02% can stimulate scleral melting.

Purpose: To retrospectively study the indications, graft
survival, and visual outcome of PPPKP performed in                        LASIK Complications: The Art of Management
children 12 years of age or younger at KKESH between
January 1, 1990 and December 31, 2003.                                    Khaled Ahmed Abdelrahman
Results: 165 PPPKP were performed in 134 children during
the study period. The surgical indications were congenital                Flap-related complications: Epithelial defect. Striae and
opacities in 130 eyes (78.8%), acquired traumatic opacities               wrinkles, Buttonhole, Thin flap, Complete cut (free cap),
in 18 eyes (10.9%), and acquired nontraumatic opacities in                Incomplete cut (partial), Irregular or eccentric cut, Displaced
17 eyes (10.3%). Among congenital opacities, 35 cases were                or dislocated flap. Interface complications: Microbial
caused by congenital hereditary endothelial dystrophy                     Keratitis, Epithelium ingrowth, Diffuse lamellar Keratitis,
(CHED). Kaplan-Meier graft survival was significantly higher              FB. Sensory denervation: Due to cutting corneal nerve
at all postoperative intervals in eyes with CHED than for                 plexuses by microkeratome, nasal hinge is better than
other surgical indications (p < 0.001). Eyes with CHED were               superior. It leads to defective vision due to microerosions
significantly more likely to achieve ambulatory vision or vision          of the epithelium. If so severe, it may lead to flap melt.
> 20/200 than eyes with other indications (p < 0.001).                    Refractive complications: Under or overcorrection or
Conclusions: PPPKP was associated with an excellent                       astigmatism. Regression, Decentration, Aberration,
prognosis for graft survival in eyes with CHED and fair                   Keratectasia, Glare.
prognosis for graft survival in eyes with non-CHED
congenital opacities and acquired opacities. The best visual
prognosis was obtained in eyes with CHED and the worst                    Evaluation of Corneal Curvature and Thickness in
prognosis was for non-CHED congenital opacities.                          Posterior Microphthalmos

                                                                          Sawsan R. Nowilaty, Zohair Al-Jishi, and Abdulrahman H
Scleral Melting After Suture Removal in Pterygium                         Al-Gaeed
Surgery and Topical Mitomycin
                                                                          Purpose: To assess the type and the consistency of changes
Gholamhossin Yaghoubi, Mohammad Hossein Davari,                           in corneal curvature and thickness in posterior
Behrouz Heydari and Abbas Hosseinirad                                     microphthalmos, a condition in which the posterior segment
                                                                          is disproportionately small compared to an anterior segment
Purpose: To report scleral melting after suture removal in                of normal size.
pterygium surgery with 0.02% topical mitomycin-C.                         Methods: Nine patients aged 7 to 45 years from four sib-
Methods: Case report                                                      ships presented with typical bilateral posterior
Result: A 40-year-old man attended to emergency clinic with               microphthalmos. The eyes underwent a prospective detailed
severe headache, nervousness and seizure-like pattern after               eye examination, ocular standardized A-scan echography,
2 days of conjunctival suture removal. The patient has                    corneal topography and pacchymetry.
pterygium excision in one month and used topical                          Results: All 18 eyes had a normal external appearance and
mitomycin-C 0.02% thereafter for one week. The                            marked hyperopia ranging from +8.50 to +16.50 (average
neurological examination and imaging (Ct-Scan) were                       +13.00). The short axial lengths (15.5 - 19.8 mm, average
within normal limit. In ophthalmological consultation, the                16.65 mm) were due to short vitreous compartments (8.3 -
visual acuity was 10/10 in both eyes .The right eye has                   12.4 mm.). Funduscopy revealed the typical papillomacular
conjunctival hyperemia and scleral melting in the                         fold or radiating macular striae. All eyes had normal-
inferotemporal side of limbus. The patient was transferred                appearing anterior segments. Corneal diameters (11.2 -12.5
to ophthalmic ward and took tranquilizer and topical vitamin              mm), central anterior chamber depth (3.0 –3.5 mm) and
A ointment, artificial tear and ciprofloxacin drop. The severe            lens thickness (3.9 – 4.6 mm) fell within normal dimensions
headache and nervousness subside and scleral melting begun                when correlated for age. Increased corneal curvature, however
to heal with vascularisation in the scleral melting area.                 was a consistent finding in all eyes. K-readings ranged
Conclusion: Conjunctival suture removal after one month                   between 44 – 51.5 diopters (average 48.5D) and increased

                                     Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                 93
     Saudi Ophthalmology 2007
     with decreasing axial length of the globe. Although increased            pigmentovascularis, Sturge-Weber syndrome and ocular
     scleral and retinochoroidal thickness was a constant finding,            evidence of both conditions. Phacomatosis pigmentovascularis
     corneal thickness was normal (500 – 590 microns, mean                    is a rare condition characterized by coexistence of naevus
     550) in 14 eyes, and was slightly increased to 610 microns               flammeus and pigmentary naevi. We describe the clinical
     in four eyes of two patients.                                            presentation of this patient. Noting that this is the second
     Conclusions: Increased corneal curvature is a constant finding           phacomatosis pigmentovascularis case described in a Saudi
     in eyes with posterior microphthalmos and appears inversely              patient, this is the first glaucoma case associated with
     proportional to the degree of ocular shortening. Corneal                 phacomatosis pigmentovascularis in Saudi Arabia.
     thickness on the other hand, is frequently normal despite
     scleral wall thickening. Increased corneal curvature, in
     particular, appears as compensation for the short axial length.          Outcome of Capsule Excision Due to Bleb
                                                                              Encapsulation After Ahmed implant

     Comparison of the Effects of Oral Clonidine with                         Sami Al-Shahwan, Ohood Oweidi, Marwan Abouammoh
     Oral Diazepam on IOP and Hemodynamic                                     and Jose Morales
     Stability After Succinylcholine Injection and
     Intubation in Cataract Surgery                                           Background and Objective: To assess the outcome of surgical
                                                                              intervention for bleb encapsulation after Ahmed implant.
     Hamid Zahedi, Nikoseresht Mahshid and Rahrotaban Marjan                  Patients and Methods: We reviewed the records of 9 patients
                                                                              who developed bleb encapsulation after Ahmed implant and
     Purpose: In this study, we evaluated the effects of oral                 underwent bled revision because of failure to medical
     clonidine with oral diazepam as premedication on IOP and                 treatment.
     hemodynamic stability after injection of succinylcholine &               Results: After a mean follow-up of 57 months (range 6 to
     intubation in cataract surgery.                                          180), the mean IOP (17.37 ± 4.95) after bleb revision was
     Methods: 109 patients with PS-ASA 1-2 were randomly                      significantly lower than the mean preoperatively IOP (30.77
     allocated to 2 groups. The experimental group (54 cases)                 + 4.65) {P value <0.05}. Successful outcome was defined as
     was treated with oral clonidine (3 mic/kg) and the control               a final IOP between 6 and 22 mmHg with the same or less
     group (55 cases) was treated with oral diazepam (0.15 mg/                medication than pre-operatively and was achieved in seven
     kg) 2 hours before G.A. as premedication. All of patients                eyes (77.80%).
     under G.A have given sodium thiopental (5mg/kg), fentanyl                Conclusion: Capsular excision after failed Glaucoma Ahmed
     (2mic/kg) & succinylcholine (1.5mg/kg). HR,BP,MAP were                   Implant is a useful alternative in lowering the IOP in patients
     recorded before and 2 hours after premedication,                         who develop fibrous capsule formation and do not respond
     immediately after intubation, 5th & 10th minutes after IV                to medical therapy.
     injection of succinylcholine. IOP were measured with schiotz
     tonometer before and 2 hours after premedication, 5th &
     10th minutes after IV injection of succinylcholine.                      Confirmation of the Presence of Mycobacterium
     Results: In both groups, IOP5 & IOP10 were significantly                 Leprae in Suspected Ocular Leprosy Patients by
     decreased, with more significance in experimental group.                 Histopathology and Genetic Analysis
     There was a significant decrease in SBP & MAP after
     intubation and gradually decreased in 5th & 10th minutes,                Farrukh A. Shamsi, Imtiaz A. Chaudhry, Milton O. Moraes,
     which was more stable in experimental group. HR has more                 Hamad Al-Fraikh, Alejandra N. Martinez, Abdulwahab Al-
     stability in experimental group.                                         Theeb and Fenwick C. Riley
     Conclusion: These results indicate that oral clonidine as
     premedication is more appropriate for reduction of IOP and               Purpose: To report detection and diagnosis of ocular leprosy
     hemodynamic stability in patients who undergo cataract                   by histopathology and its confirmation by genetic analysis.
     surgery with G.A after IV injection of succinylcholine.                  Methods: Clinical records of patients with no known history
                                                                              of leprosy seen at King Khaled Eye Specialist Hospital were
                                                                              reviewed. Excised tissue from a clinically suspected ocular
     Glaucoma in Phacomatosis Pigmentovascularis                              leprosy patients were processed and histopathologically
     Type II B Associated with Sturge-Weber Syndrome                          analyzed. The DNA from paraffin embedded tissues was
                                                                              extracted, an 85 A-C intergenic region of Mycobacterium
     Sami Al-Shahwan and Marwan A. Abouammoh                                  leprae was amplified using specific primers and analyzed by
                                                                              conventional as well as real-time polymerase chain reaction
     We report a 28-year-old lady with phacomatosis                           (rtPCR).

94                                       Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                Saudi Ophthalmology 2007
Results: Among the 5 patients (4 females, 1 male; average                55kDa. LC alone increases the activity of GSH in the RPE
age 55 years), only 2 were found to have leprosy from clinical           cells; and in the presence of stressors has the capability to
examination alone. With Periodic Acid Schiff-Haematoxylin                further enhance the activity of the enzyme.
(PAS-H) staining the presence of thin fibrinous layer of                 Conclusions: The results of this study demonstrate that LC
inflammatory cells could be seen in the specimens. Most of               may reduce the deleterious effects of oxidative stressors on
the tissues were fibrovascular with extensive infiltration by            the on the mitochondria, protect the RPE proteins and
histiocytes having reticulate cytoplasm. Modified PAS-H and              enhance the GSH activity as a sign of increased protection
Acid-Fast staining (AFS), suggestive of leprosy, was positive            against oxidative insult. Although more studies are required
in 4 patients and the staining showed the presence of several            to conclusively prove the true potential of LC as a protectant
AFS organisms within the cytoplasm of histiocytes and mast               in the eventuality of radical damage, our results have clinical
cells. Conventional PCR showing a 250bp DNA from excised                 significance and call for attention to a new therapeutic
tissues in 4 specimens was in agreement with the positive                approach with simple dietary supplements, particularly LC,
controls for M. leprae. In one specimen through rtPCR, it                for the treatment of various eye diseases.
was calculated that the suspected tissue had 44.68pg of M.
leprae DNA, which is 8937.06 genome copies of M. leprae.
Conclusions: Presence of inflammatory cells and AFS bacilli              Initial Diagnosis of Leprosy in Patients Presenting
in tissues present a typical picture of leprosy. M. leprae DNA           to an Ophthalmologist in a Tertiary Eye Care
can be detected using rtPCR in ocular tissues when AFS bacteria          Center
are seen in histopathological sections. When the diagnosis of
leprosy is inconclusive and AFS bacteria are seen, rtPCR for             Imtiaz A. Chaudhry, Farrukh A. Shamsi, Elsanusi Elzaridi,
M. leprae DNA could be used as a rapid confirmatory test to              Abdulaziz Awad, Hamad Al-Fraikh, Mohammed Al-Amry,
identify the presence of M. leprae and, therefore, PCR may be            Hassan Al-Dhibi and Fenwick C. Riley
considered as a new tool in the diagnosis of leprosy when other
means of identification are not helpful.                                 Purpose: To report initial diagnosis of leprosy among patients
                                                                         presenting to an ophthalmologist in a tertiary eye care center
                                                                         with no known prior history of the disease.
L-Carnitine is Capable of Protecting the RPE Cells                       Methods: Clinical records of patients with no known history
and GSH Activity from Oxidative Stress                                   of leprosy seen by ophthalmologist at King Khaled Eye Specialist
                                                                         Hospital were reviewed for their demographics, presenting
Farrukh A. Shamsi, Imtiaz A. Chaudhry and Ali A. Al-Rajhi                symptoms, diagnostic studies and treatment outcome.
                                                                         Results: Among the 6 patients (5 females, 1 male; average
Purpose: To study the detrimental effects of oxidative stress            age 55 years), only 2 were found to have leprosy from clinical
on human retinal pigment epithelial cells (RPE) and                      examination alone. Histopathological features or
glutathione (GSH) activity and to examine the ability of L-              demonstration of AFB suggestive of leprosy were found in 5
carnitine, a ‘conditionally essential nutrient,’ to reduce or            patients, definite confirmation was made by PCR in 4 cases.
prevent such damage.                                                     Conclusion: The diagnosis of leprosy relies on the clinical
Methods:The effiect of oxidative stressors (peroxide and                 symptom complex, epidemiology and demonstration of acid-
riboflavin), in presence or absence of light was evaluated on            fast bacilli in the tissue sample. Considering that the global
the RPE cells cultured from human donors. The RPE cells                  leprosy population is 12 million, a patient with leprosy may
were treated with 100mM stressor for 5-hour under light                  be found anywhere. The ophthalmologist may be the first
and the effect of 100mM LC on mitochondria, primary site                 one to encounter such patient in which case suspicion and
of oxidation in the RPE, was investigated by staining with               detection of ocular findings may lead to early treatment of
mitotracker-green and visualization by fluorescence                      infection. PCR may be a new tool in the diagnosis of leprosy
microscopy. The effect of stressors and or LC on the RPE                 when other means of identification are not helpful.
protein was analyzed by SDS-PAGE. The effect of stressors
and the role of LC on antioxidant GSH activity were studied
by specific assay.                                                       Eyelid Melanoma
Results: Fluorescence microscopy showed that the
mitochondrial damage in the RPE cells can be prevented by                Nafise Hamid Esmaili, H. Emami Razavi and Z. Emami
treating them with LC. Exposure to 5-hours of white-                     Razavi
incident-light was sufficient to cause damage to
mitochondria in the RPE cells. It was observed that LC was               Eyelid skin melanomas have a relatively good clinical
able to prevent stress induced protein damage to the RPE                 prognosis. We reported three cases of eyelid melanoma that
proteins, particularly in the low MW region of 14kDa to                  survived more than 5 year, and as it seems had complete

                                    Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                  95
     Saudi Ophthalmology 2007
     response to treatment modalities. Two of them were female.                Conclusions: The OCT exam is capable of demonstrating
     Melanoma lesions of all were on upper eyelid. They had 55                 the progressive anatomic changes in the retina and RPE in
     year, 64 year and 73 years old. Lentigo maligna melanoma                  patients with Best’s vitelliform macular dystrophy and is
     was the most common histologic type. All primary lesions                  therefore an excellent non-invasive tool to follow the
     of eyelid melanoma excised. Excision were complete and                    progression of the disease and explain the changes in VA.
     surgical margins were free.They survived the first for 8 year,
     the second for 5 year and the third for 6 year . In our cases
     upper eyelid melanoma with lentigo maligna melanoma                       A Retrospective Review of 23 Cases of Pseudotumor
     histopathologic, finding had good 5 year survival.                        of the Orbit Diagnosed at King Faisal Specialist
                                                                               Hospital and the Massachusetts Eye and Ear Infirmary
     A Retrospective Study of Effect of Macular                                Alfred Weber and Keith Wedin
     Photocoagulation on CSME of Diabetic Patients
     with and without Hypertension and Comparing                               Pseudotumor of the orbit, not commonly seen in most
     Two Groups                                                                ophthalmologic practices, is encountered 2 to 3 times a year at
                                                                               the ophthalmology clinic at KFSH, a tertiary care referral center
     Morteza Movassat                                                          in Riyadh, Saudi Arabia. Diagnosis depends primarily on
                                                                               interpretation of the appearance of the lesion on a computed
     In a retrospective study in a period of one year, Aug.                    tomography (CT) scan because biopsy of infiltrative tissue in
     2005MPC-Aug. 2006, all patients with CSME who were                        the orbit for a definitive diagnosis is risky. We reviewed the
     treated with MPC were evaluated for the result of treatment.              records of 23 cases of pseudotumor of the orbit diagnosed at
     Patients were classified in 2 groups, one group the patients              KFSH and MEEI from 2002 to 2006. The primary imaging
     without high blood pressure and another group the patients                modality was CT and occasionally magnetic resonance imaging
     with high blood pressure. The patients in these two groups                (MRI) in cases where the tumor extended outside the orbit
     were classified again for BCVA, severity of CSME, high                    and afflicted the globe or extended to the cavernous sinus. CT
     cholesterol and T/G, smoking, duration of diabetes and A1C                scans were available in 23 cases and MRI in 2 cases. The imaging
     hemoglobin and matched in two principal groups of high                    findings revealed the following features and locations: The
     or normal blood pressure.                                                 infiltrative tissue involved only the muscles (myositis type),
     Result: Effect of MPC in CSME in DR is very better in                     especially the lateral rectus muscle, in 6 cases; caused muscle
     patients without high blood pressure, and patients with high              enlargement with associated infiltrations in the orbital fat in 6
     blood pressure especially high diastolic pressure don’t                   cases; consisted of diffuse ill-defined orbital infiltrations in 6
     response so well to MPC and perhaps it is better to use anti-             cases; was confined to the orbital apex in 2 cases; was
     VEGF factors as intro-ocular Avastin in association with                  homogenous, presenting as a mass mimicking a tumor in 1
     MPC in these cases.                                                       case, and extended to the superior orbital fissure and cavernous
                                                                               sinus (Tolosa-Hunt syndrome) in 2 cases. On CT, the
                                                                               infiltrations were isodense with muscle, were often ill-defined,
     Correlation of Optical Coherence Tomography                               and showed from slight-to-marked enhancement, depending
     Findings and Visual Function in Best’s Vitelliform                        on the evolution of fibrosis, with diminution of enhancement
     Macular Dystrophy                                                         in cases with advance fibrosis. In some case, pseudotumor has
                                                                               a typical clinical manifestation and a positive response to steroids,
     Eman Kahtani and Sawsan R Nowilaty                                        clinching the diagnosis. The imaging findings in these cases
     Purpose: To report the OCT appearance and its correlation                 are further proof of the diagnosis of pseudotumor. However,
     with both the stage of the disease and the visual function in             there are cases where the clinical findings are inconclusive and
     a case of Best’s vitelliform macular dystrophy.                           imaging often suggests or confirms the clinical diagnosis. In
     Methods: The OCT was performed in a 5-year-old boy to                     cases with atypical clinical manifestations and biopsy with
     elucidate the pathogenesis of Best’s disease and its correlation          inconclusive histopathology follow-up of the patient with
     with visual function.                                                     rebiopsy is indicated.
     Results: The OCT demonstrated that in the right eye with
     significant intra-RPE accumulation of lipofuscin and a
     reasonably anatomically unaltered neurosensory retina, the                Ligneous Conjunctivitis Revisited
     VA was reasonably preserved. However in the left eye where
     the vitelliform lesion was characterized by RPE atrophy and               Amal Al Hemidan and Khalid Tabbara
     secondary neurosensory retinal structural changes, the VA
     was more affected.                                                        Ligneous Conjunctivitis is a pseudomembranous rare form

96                                        Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                                 Saudi Ophthalmology 2007
of chronic conjunctivitis. The severe form of the disease is              in central zone and on equator till 175±3.3 and 163±3.1 micron
associated with trachobronchial, cervical, middle ear and                 accordingly. In 15% the dimensions of transverse diameter
gingival mucosal involvement with or without obstructive                  exceeded the dimensions of anteroposterior axis for 1,5 mm
hydrocephalus.                                                            and more: -27,3±0,05 mm and 25,8±0,04 mm correspondingly,
Method: The first report of homozygous type I plasminogen                 eye was shaped like prolated ellipse. The dystrophic changes
deficiency was in a Turkish girl 18 months old who presented              located more frequently on periphery of fundus in form of
to the children’s hospital of Wurzburg University in Germany              vitreochorioretinal dystrophies, and central zone was relatively
in 1994 with congenital hydrocephalus and LC. Until 2003,                 safe. In this group of patients myopia was more progressive.
119 have been reported in the world literature but of course              Thickness of retina in central zone in this group of children
many separate cases have not been reported the true                       amounted to 180±2.9, on equator - 154±4.2 micron. In 60,5%
incidence is not known. Later Drew, Kaufmar and associates                of children echobiometrical indexes increased in
reported the occurrence of LC in plasminogen – deficient                  anterioposterior axis and transverse-horizontal diameter of eye,
(plg Ø / Ø) mice in 1998. The severity of the disease is                  eye was shaped like ball but enlarged in size. Echobiometrical
inversely related to the level of functional plasminogen                  indexes exceeded age norm for 1,5 mm and more (25,9 mm
activity which is inherited as an autosomal recessive.                    and 26,0 mm). In these cases the marked changes on fundus
Results: Many modalities of Rx have been tried, the authors               were observed in central zone and on periphery in form of
reports their experience in managing a different case of LC.              myopic cones, rings, staphylomas, absence of macular reflexes,
Conclusion: Ligneous Conjunctivitis is rare uncommon                      redistribution of pigment in macula and on periphery. Myopia
form of chronic conjunctivitis that usually affects children.             was slow- progressive. Optic coherent tomography of retina
Girls more than boys but may occur at any age. LC appears                 revealed thinning of retina in central zone till 178±3.4, on
to be the ocular manifestation of a systemic disease which                equator 158±3.2 micron.
might be accompanied by formation of a pseudomembrane                     Conclusions: Pathological changes on fundus in children
on the mucosa of the mouth,kidneys, larynx, brain,and other               with progressive myopia are in direct relation with the
sites Plasminogen replacement therapy lead to rapid                       changes of eye parameters – anterioposterior and transverse
regression of the psuedomembrane. Both locally and                        diameter. Spheroid form of eye ball occurs most frequently
systemically, ligneous conjunctivitis is a serious disease and            in congenital myopia.
may lead to blindness and death in some patients. Treatment
is high cost but effective.
                                                                          Lisch Nodules in Noonan Syndrome

Peculiarities of Current of Progressive Myopia in Children                Abdullah M. Al-Fawaz, Adel H. Al-Suhaibani and Hailah
Aubakirova A.Zh., Iskakbaeva D.S., Toksanbaeva G.K.
                                                                          Purpose: To present a child developed bilateral Lisch nodules
Purpose: To study the eye parameters and changes of fundus                years after been diagnosed to have Noonan syndrome.
in children with progressive myopia.                                      Methods: Patient evaluation included: complete general and
Material and Methods: 234 children (448 eyes) from 6 to                   ophthalmic examination, and imaging studies.
14 years-old with average and advanced stage of myopia were               Results: Finding bilateral Lisch nodules raised the possibility
examined by method of ultrasound echobiometrics, studied                  of neurofibromatosis-Noonan syndrome in 8 -year-old Saudi
localization of the chorioretinal changes on eye fundus                   boy diagnosed previously to have Noonan syndrome.
depending on parameters of eye.                                           Conclusion: Signs of neurofibromatosis may appear years after
Results: Children with congenital myopia constituted 53,8%,               the diagnosis of Noonan syndrome. This mandates periodic
with early acquired myopia- 33,5% and with scholar myopia –               ophthalmic evaluation as ophthalmologist may find the first
12,7%. Rapidly progressive myopia was diagnosed in 85%. In                clue of diagnosing neurofibromatosis-Noonan syndrome.
24,5% of children mainly extension of anteroposterior axis was
observed in comparison with transverse diameter at 1,6+0,14
mm and more in average amount to 26,5±0,03 mm and                         Congenital Stromal Cyst of the Cornea
25,0±0,05 mm correspondingly, eye was shaped like ellipse.
Changes on fundus had some peculiarities: dystrophic lesions              Arif O. Khan, Hind Al-Katan, Saeed Al-Gehedan and
located mainly in central zone in form of myopic crescent,                Waleed Al-Rashed
stretching of retina and redistribution of pigment in macula
and around the disk, presence of pathology reflexes or weakening          Purpose: To describe a novel form of congenital corneal
of macular and foveolar reflexes. Myopia was more hospital.               abnormality.
Optic coherent tomography of retina revealed thinning of retina           Methods: Retrospective case report.

                                     Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                  97
     Saudi Ophthalmology 2007
     Results: A one-month old otherwise-healthy girl had bilateral             valve of Hasner. The defective lacrimal drainage is about
     diffuse blue-grey discoloration of the cornea except for a                20% in the children before their first year of life that more
     central 5 mm circular area, which clinically appeared clear.              than 90% of them recovery spontaneously. In this study,
     Ultrasound confirmed a cystic structure in the posterior                  considering that air injection has no risk of aspiration it’s
     stroma corresponding to the clear area. At age eleven months              used instead of saline injection.
     the child underwent emergent penetrating keratoplasty in                  Purpose: To compare the success rate of the conventional
     both eyes because of angle-closure glaucoma. Intraoperative               method of probing (probing and saline irrigation) with the
     inspection and histological study confirmed a cyst occupying              method of probing and air insufflations.
     a central posterior corneal excavation in both eyes.                      Methods and materials: The 61 children’s, 76 eyes (9-24
     Discussion: Although our case best fits into the spectrum                 month age) with diagnosis of congenital nosolacrimal duct
     of Peters anomaly, a MEDLINE search from 1902-2006                        obstruction that the conservative treatment was not
     failed to reveal any previous descriptions of congenital                  successful, undervent of nasolacrimal duct probing. All
     intracorneal cysts in this (or any other) setting. We postulate           Patients have lacrimal massage and antibiotic drop post
     that during ocular development persistence of the primary                 probing. The children were assessed before and after probing
     pupillary membrane with abnormal adhesion to the                          by Munk’scale. Patients’ follow – up was conducted in 3
     developing corneal endothelium led to this patient’s novel                times; 2 weeks, 1 month and 3 months respectively after
     congenital abnormality.                                                   the procedure. A few numbers of patients were omitted from
                                                                               the research because of their irregular attendance in the
                                                                               follow up program.
     Presenting Clinical Features Suggestive for Later                         Results: Of 30 patients under probing and saline irrigation
     Recurrence of Idiopathic Sixth Nerve Paresis in Children                  the following results were achieved post operatively:; in the
                                                                               2 weeks after the procedure 31 eyes (86.1%), 1 month after
     Arif O. Khan and Salman J. Yousuf                                         the procedure 34 eyes (94.4%) and 3 months after the
                                                                               procedure 34 eyes (94.4%) probing was successful. Indeed
     Although idiopathic sixth nerve paresis of childhood typically            of total 31 patients under probing and air i insufflations the
     resolves within a few months, in a minority of cases the                  results were achieved was; in the 2 weeks after the procedure,
     paresis recurs. The purpose of this study is to describe                  33 eyes (82.5%), 1 month after procedure 38 eyes (95%)
     presenting clinical features associated with recurrence.                  and 3 months after procedure 38 eyes (95%) probing
     Methods: Single case report and retrospective literature                  successful=0.92. Of 34eyes belonging to male sex during
     review.                                                                   eventual follow up (3 month post operatively) 33 eyes were
     Results: Fifty-four non-recurrent and 42 recurrent cases were             cured and from a total 42 eyes belonging to female sex during
     identified. Patients with recurrence were typically girls                 eventual follow up (3 months post operatively) 39 eyes
     (p<0.05) affected in the left eye (p<0.05). All children who              (92.3%) were cured.
     presented under 14 months of age developed recurrence,                    Conclusion: The study show that the eventual result of
     and no children who presented after 12 years of age                       probing and air injection in comparison to probing and
     developed recurrence.                                                     saline injection had not statistically significant difference,
     Conclusions: When a child is diagnosed with idiopathic sixth              so probing with air insufflations have not anesthesia
     nerve paresis, clinical features suggestive for later recurrence          complication and we offer this approach in probing.
     are female gender, left eye involvement, and young age.

                                                                               Management of Congenital Unilateral Proptosis
     Probing with Air Insufllation Compared with                               from an Orbital Epithelial Cyst by Cyst Aspiration
     Probing and Irrigation in Children with Congenital
     Nasolacrimal Duct Obstruction                                             Adel H Al-Suhaibani, Hailah Al-Hussein, Hind Al-Katan
                                                                               and Arif O. Khan
     Behrouzr Heydari, Gholamhossin Yaghoubi,
     Mohammdhoussein Davari, Mohamad Reza Miri and                             Purpose: To report a case of severe congenital unilateral
     Hassan.Massoudian                                                         proptosis secondary to an orbital epithelial cyst and its
                                                                               management by needle aspiration.
     Congenital nasolacrimal duct obstruction (CNLDO) is a                     Methods: Retrospective case report.
     common disorder that is characterized by tearing and mucoid               Results: An otherwise healthy boy was born with esotropia
     or mucopurulent discharge. The most common site of                        and severe right proptosis. Magnetic resonance imaging
     obstruction is at the mucosal entrance into the nose (the                 revealed a large orbital cyst without intraocular or intracranial

98                                        Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007
                                                                                               Saudi Ophthalmology 2007
connection. Needle aspiration of the cyst significantly                 was drug abuse in 87% and sexually contact in 34%.only
reduced the proptosis, and a biopsy of the cyst wall taken at           one patients was infected transplacentally. The most
the same time revealed stratified nonkeratinized squamous               common ocular complications were Cotton wool spots
epithelium without goblet cells. At two years’ follow-up the            (12.2%) and posterior uveitis (12.2%). One cases of CMV
cyst has not reformed but the affected eye has limited vision           retinitis was observed in a 40 years man.
secondary to amblyopia.                                                 Conclusion: It seems that in HIV+ patients HAART regimen
Conclusions: Congenital intraorbital epithelial cyst can be             partially can control ocular complications.
managed by needle aspiration rather than surgical resection.
Aggressive amblyopia treatment is required for visual
rehabilitation in such cases.                                           Prevalence of Trachoma in Desert Districts of Al-
                                                                        Jawf Governorates in the Republic of Yemen

Ocular Complications in Human Immune                                    Abdullah Mohammed Al-Kuhany
Deficiency Virus Positive Patients

Ali Abdollahi, Mohammad Hossein Malekmaadani and                        This study is aimed to find out the active trachoma trichiasis,
Minoo Mohraz                                                            their prevalence and trachoma risk factors. Prevalence of
                                                                        Trachoma in desert districts of Al-Jawf Governorates –
Purpose:                                                                Republic of Yemen during October 2005 to May 2006 Epi.
Acquired Immune Deficiency Syndrome (AIDS) is a                         Info2000 study computer program were used to determine
potentially fatal syndrome which usually underlies the                  the start finger and determine clusters. In the governorates
opportunistic infections. In this syndrome many organs may              all desert districts were chosen and determine 25 clusters
be involved. Ocular complications include: Cytomegalovirus              for the study. A total of 640 children between the ages of
(CMV) retinitis, uveitis, Varicella Zoster virus retinitis,             more than 3 months to 9 years examined for the signs of
Herpes Simplex virus retinitis, Toxoplasmic retinochroiditis,           active trachoma 225 more than 40 years for trachiasis. The
Kaposi sarcoma, conjunctivitis, herpetic keratitis, fungal              examination was conducted in each cluster of targeted
keratitis.                                                              peoples in their homes using a binocular loupe with x 2.5
Method: In a cross-sectional study a total of 41 HIV+                   magnification.
patients (38 male and 3 female) were studied. All of them               Active trachoma cases were found affecting the children of
were under the Highly Active Retroviral Therapy (HAART).                Al-Jaw, trichiasis was not found and the endemic
Ocular examination by an expert ophthalmologist with slit               governorates, represent high percentages of children with
lamp and indirect ophthalmoscopy was done.                              unclean faces. The risk factors of trachoma like unclean faces
Results: Most of the patients with ocular complications were            of children, presence of solid waste and houses with no
in the range of 30-40 years and the route of contamination              latrines were found.               (Read more on the Poster!)

                                   Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007                                 99
      Saudi Ophthalmology 2007

                                                         Video Abstracts
      Anterior Lamellar Keratoplasty at 400 Microns                               leave parts of it, or you might cause some damage to the corneal
      Depth and 8 mm Diameter with INTRALASE in                                   stroma while removing it. This Video will show you how easy it
      Keratoconus                                                                 is, and how can you be sure that all the Descemet’s membrane is
                                                                                  removed and the stroma is saved from trauma.
      Khaled Ahmed Abdelrahman

  Purpose: To use INTRALASE for cutting Deep Lamellar
                                                                                  The Value of Anterior Chamber Air Bubble During
  cornea layers for anterior Lamellar Keratoplasty in Keratoconus.                Deep Anterior Lamellar Keratoplasty
  Methods: To use INTRALASE machine with SN:0205
  20097 for cutting 400 microns thick and 8 mm diameter                           Khalid Al-Arfaj
  from the cornea of a recipient with central ultrasonic
  pachymetry of 461 microns, then to remove the corneal                           Aims: The aim of this video presentation was to assess the value
  tissue from the recipient and suturing of 8 mm diameter                         of anterior chamber air bubble during deep anterior lamellar
  corneal donor with removed Descemet’s membrane by 10/                           keratoplasty (DALK) by visualizing the Descemet’s membrane
  0 Nylon continuous suture.                                                      during the procedure. This allows the surgeon to determine the
  Results: Anterior Lamellar Keratoplasty was done                                location of Descemet’s membrane and avoid any injury to it.
  uneventful with a time        saving maneuver and save and                      Methods: Video presentation of one keratoconus case done in
  efficient way by the aid of INTRALASE.                                          K.K.E.SH Air was injected in anterior chamber thru paracentesis
  Conclusion: INTRALASE is a promising tool for the use                           after full big bubble stripping Descemet’s membrane and
  of Anterior Lamellar Keratoplasty in the outcome of the                         endothelium from the posterior corneal stroma.
  surgery regarding time saving and safe manipulation.                            Results: This method is helpful in aiding the surgeon during
                                                                                  the surgery
                                                                                  Conclusions: This technique may help the surgeon during
      Combined Posterior Enclavation Aphakic Artisan                              DALK.
      with Anterior Vitrectomy in Aphakic Eye with
      Previous Penetrating Keratoplasty
                                                                                  Combined Penetrating Keratoplasty, IOL Removal,
      Khaled Ahmed Abdelrahman                                                    Anterior Vitrectomy, Scleral Fixated IOL and
  Purpose: To introduce a new technique for implantation of
  Artisan lens in Aphakic eyes.                                                   Khalid Al-Arfaj and Saeed Al-Gehedan
  Methods: One eye of a young female who underwent
  previous combined ECCE and PKP for congenital cataract                          Complicated cataract surgery with Anterior chamber IOL
  associated with keratoconus , was complainig of bad vision                      continues to be one of the presenting problems with.
  due to Aphakia.                                                                 decompensated cornea and distorted pupil. Here we are
  This female underwent uneventfull Aphakic Artisan with                          reporting a patient with sector iridectomy and anterior
  posterior enclavation combined with anterior vitrectomy.                        chamber iol and decompensated cornea treated by PKP ,
  Results: Uneventfull surgery which was short durration, safe,                   IOL removal, anterior vitrectomy, Scleral Fixated IOL and
  predictable and easy technique.                                                 Pupilloplasty resulting in excellent cosmetical apperance
  Conclusion: Posterior enclavation Aphakic Artisan is easy                       and excellent visual outcome.
  safe, predictable and time safing surgery.

                                                                                  Scleral Fixated IOL with Pupilloplasty
      Removal of Donor Descemet’s Membrane Using
      Vision Blue in Deep Lamellar Keratoplasty                                   Saeed Al-Gehedan

      Abdullah Al-Assiri                                                          Aphakia continues to be one of the presenting problems
                                                                                  sometimes bothering both the patient and the surgeon. It is
      This is a video presentation showing how vision blue can be                 usually accompanied by distorted pupil resulting in light
      useful in removing Desemet’s membrane in donor’s cornea for                 intolerance by the patient. Here I am reporting a patient
      deep lamellar keratoplasty. In fresh cornea or in younger age               with sector iridectomy and surgical aphakia treated by scleral
      group donor’s cornea, sometime it is difficult to peel the Desemet’s        fixated IOL & pupilloplasty resulting in complete anatomical
      membrane due to strong adhesion to the stroma and you might                 reconstruction and excellent visual outcome.

100                                          Saudi Journal of Ophthalmology, Volume 21, No. 1, January – March 2007

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