AIM: To evaluate the incidence and severity of ocular graft versus host disease (oGVHD) in patients who underwent allogeneic stem cell transplant (SCT) in King Abdul-Aziz Medical City, Saudi Arabia. METHODS: This is a retrospective cohort study conducted in King Abdul Aziz Medical City on patients who underwent allogeneic hematopoietic cell transplant (allo-HCT) from 2010 to 2017. The ocular examination findings including visual acuity, meibomian gland dysfunction, corneal and conjunctival staining with severity, corneal scarring, tear film meniscus and breakup time, anterior and posterior segment examination findings, intraocular pressure, treatment given, punctual plugs used or not, and follow up response were collected. RESULTS: The five years cumulative incidence of oGVHD among post-transplant patients was 56.98% (95%CI 38.6%-71.7%). The potential risk factors assessed for developing ocular manifestation were age, gender, donor’s age, donor gender mismatch CD3 and CD34 infusion, while none of the correlates were identified as statistically significant risk factors of developing ocular manifestation. However, the incidence was statistically significantly different between patients diagnosed with acute myelocytic leukemia and acute lymphocytic leukemia (P=0.038). The mean latent period to develop ocular symptoms was 20.5mo. All patients had variable degree of dry eyes. None of the patients developed any posterior segment complication. CONCLUSION: The incidence of oGVHD is low in King Abdul-Aziz Medical City. This can be attributed to the preconditioning and immunosuppressive regime.

PURPOSE: To determine the prevalence of refractive errors among Saudi adults in Riyadh, Saudi Arabia. METHODS: A cross-sectional study was conducted targeting healthy Saudi adults (20–40 years old) at two major gatherings in Riyadh, Saudi Arabia from December 2018 to January 2019. Refractive errors were measured, and data pertaining to age, sex, region of origin, and spectacle use was collected. Clinically significant myopia was defined as SE ≥ -0.50 D, hyperopia as SE ≥ 0.50D, and astigmatism as cylindrical error ≥ 0.50D. Refractive error measurements were assessed using Topcon's Auto-Kerato-Refractometer, KR-800. RESULTS: A total of 660 adult individuals (1,319 eyes) were included in this study, of which 321 participants (48.7%) were found to be myopes, 167 subjects (25.2%) were hyperopes, and 438 individuals (66.3%) had astigmatism. With regards to correlations, myopia was highly correlated with being male ( P -value = 0.036), belonging to age group 20–25 years ( P -value = 0.033), originating from the northern regions of Saudi Arabia ( P -value <0.001). Similarly, hyperopia was significantly correlated with being male ( P -value = 0.048), age groups 20–25 years ( P -value = 0.04), and 31–35 years ( P -value = 0.011) and was higher in people from northern region ( P -value = 0.011). In contrast, astigmatism was only found to be correlated with age group 36–40 years ( P -value = 0.002). Additionally, 71.7% of myopic participants and 76.1% of astigmatic individuals opted not to wear spectacles ( P -value <0.001). CONCLUSION: In this study, the refractive error with the highest prevalence among Saudis was astigmatism, followed by myopia and hyperopia. Gender, region of origin, and spectacle wear were all observed to be highly correlated with higher rates of refractive error.

AIM: To evaluate the causes of phakic implantable collamer lens (ICL) exchange/explantation in patients with and without keratoconus (KC) at two tertiary hospitals in Riyadh, Saudi Arabia. METHODS: A retrospective chart review of all patients who underwent ICL (model V4c with central port) exchange/explantation was performed using the electronic medical record systems. All available preoperative and postoperative data were documented for each patient. RESULTS: Over 7y, 2283 ICL implantation procedures were performed; 46 implants (2%) required exchange (21 implants)/explantation (25 implants), of which 14 cases (30.4%) were patients with KC. Indications for ICL exchange/explantation in non-KC group were vault measurement, cataract formation, increased intraocular pressure, inaccurate refraction, and patient dissatisfaction in 22 (68.75%), 4 (12.5%), 3 (9.37%), 2 (6.25%), and 1 (3.12%) case, respectively. The most common indication for ICL exchange/explantation in the KC group was inaccurate vault sizing in 11 patients (78.57%), inaccurate refraction in 2 patients (14.28%), and patient dissatisfaction postoperatively in 1 (7.14%) case. CONCLUSION: ICL implantation results in predictable refractive outcomes over the long term with exchange/explantation rates comparable to previous literature. Improper vault size is the most common cause of ICL exchange/explantation among patients with or without KC.

Purpose: To evaluate the profile of patients with post-keratoplasty complications and their presentation at an emergency center. Design: Retrospective one-armed cohort study. Methods: Data were evaluated on patients who underwent corneal grafts in 2019 and presented to an emergency unit. Data were collected on patient demographics, presenting symptoms, clinical details, diagnosis at emergency visit, final diagnosis, best-corrected visual acuity (BCVA) at presentation and at the last follow up after management. Severe visual impairment (SVI) and graft rejection were tested for correlations to other factors. Results: The study sample was comprised of 149 eyes of 124 patients with a mean age of 27.5 years. Keratoconus was indicated for keratoplasty in 94 (75.8%) patients. The main presenting symptoms were pain 57 (38.3%) and red eye in 52 (34.9%) patients. The median interval between emergency visit and keratoplasty was 1.6 years. There were 63 (42.3%) patients who had emergency visits due to suture-related problems. The rates of SVI and graft rejection at the time of discharge after managing emergencies in eyes with previous keratoplasty were 14.1% (95% CI 8.5; 19.7) and 13.4 (95% CI 7.9; 18.9) respectively. Keratoconus (OR = 22.8) and young age (P<0.001) were negatively associated to SVI after management. Conclusion: Patients with keratoplasty are at high-risk for severe vision loss and should be counselled to seek urgent eye care for early detection and management of sight threatening complications to improve graft survival and vision.

Purpose To report a case of Enterobacter cloacae (E. cloacae) keratitis in a patient who underwent corneal crosslinking (CXL) for progressive keratoconus. Observations A 19-year-old female underwent CXL for keratoconus in her left eye. The patient neglected her post-procedure medications and missed the follow-up visit. Subsequently, she presented on day-10 post CXL with redness and pain in the treated eye. Clinical examination revealed a ring-shape infiltrate measuring 7.8 mm in diameter. Culture indicated the presence of E. cloacae. Treatment with gentamicin failed after the emergence of resistance. The patient was successfully treated with amikacin and moxifloxacin over several weeks. Conclusions Judicious antibiotic selection is crucial to limit the emergence of resistance in multidrug-resistant (MDR) pathogens. All patients need to be educated about their role in the management plan.

Purpose: To evaluate the pro le of patients with post-keratoplasty complications and their presentation at an emergency center.Design: Retrospective one-armed cohort study.Methods: Data were evaluated on patients who underwent corneal grafts in 2019 and presented to an emergency unit. Data were collected on patient demographics, presenting symptoms, clinical details, diagnosis at emergency visit, nal diagnosis, best-corrected visual acuity (BCVA) at presentation and at the last follow up after management. Severe visual impairment (SVI) and graft rejection were tested for correlations to other factors.Results: The study sample was comprised of 149 eyes of 124 patients with a mean age of 27.5 years.Keratoconus was indicated for keratoplasty in 94 (75.8%) patients. The main presenting symptoms were pain 57 (38.3%) and red eye in 52 (34.9%) patients. The median interval between emergency visit and keratoplasty was 1.6 years. There were 63 (42.3%) patients who had emergency visits due to suturerelated problems. The rates of SVI and graft rejection at the time of discharge after managing emergencies in eyes with previous keratoplasty were 14.1% (95% CI 8.5; 19.7) and 13.4 (95% CI 7.9; 18.9) respectively. Keratoconus (OR = 22.8) and young age (P<0.001) were negatively associated to SVI after management.Conclusion: Patients with keratoplasty are at high-risk for severe vision loss and should be counselled to seek urgent eye care for early detection and management of sight threatening complications to improve graft survival and vision.

Purpose: The purpose of this study is to reflect anterior segment specialists’ current practice pattern regarding the management of primary pterygium. Methods: A 24-item survey regarding indications for surgery, different surgical techniques, use of adjuvant pharmacological therapy, type of intraoperative and postoperative pharmacological therapy, and the preferred treatment of early recurrences was sent to members of the Saudi Ophthalmological Society (SOS) and practicing cornea experts including consultants, specialists, and fellows in Saudi Arabia. Results: A total of 61 cornea specialists completed the questionnaire (response rate 49%). More than 95% considered the proximity of the pterygium to the visual axis an indication for excision. The most frequent technique for pterygium excision was extensive head and conjunctival resection, including the base (69%) and intermediate resection of the Tenon's capsule (53%). For conjunctival replacement, conjunctival autograft was preferred by 79%, amniotic membrane (54%), and simple conjunctival closure (46%). Interrupted vicryl sutures, fibrin glue, and combined sutures and tissue adhesive were the preferred graft fixation conveyed by 85%, 46%, and 34% of our experts, respectively. An estimated recurrence rate of 1-5% was stated by 29% of respondents and 46% reported recurrence within 6 to 12 months. Half of the respondents specified using mitomycin C intraoperatively to prevent early pterygium recurrences. When recurrence occurred, corticosteroid was the agent of choice. Conclusion: This study set out to reflect the practice pattern of anterior segment specialists regarding the management of primary pterygium, and it may serve as an insight for further studies to define the optimal management of pterygium.

The aim of this study was to compare the outcomes of 18 mW/cm 2 (5 minutes) versus 9 mW/cm 2 (10 minutes) accelerated corneal collagen cross-linking protocols in patients with progressive keratoconus. Methods:A systematic review and meta-analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and electronic information was searched to identify studies comparing the outcomes of 5-versus 10-minute protocols in patients with progressive keratoconus. Mean changes in uncorrected visual acuity, best-corrected visual acuity, cylinder (diopters), thinnest corneal thickness, corneal keratometry values (K1 and K2), corneal highorder aberration (HOA), spherical aberration, coma, and trefoil were the primary outcome measures. Secondary outcome measures included the mean change in central corneal thickness and postoperative complications. Random effects modeling was used for the analysis.Results: Four studies that enrolled 329 eyes were included. The 10minute protocol had significantly improved outcomes compared with the 5-minute protocol for the mean changes in K1 and K2 (P , 0.00001), corneal total HOA (P = 0.0002), and corneal coma (P = 0.00001). However, no statistically significant differences were found between the 2 protocols in uncorrected visual acuity, best-corrected visual acuity, cylinder, thinnest corneal thickness, spherical aberration, or trefoil. The 5-minute protocol was associated with a significantly lower mean change in the central corneal thickness for secondary outcomes. In addition, no significant differences were found between the 2 protocols for postoperative complications. Conclusions:The 10-minute protocol had better K1, K2, and HOA outcomes than the 5-minute protocol, but no statistically significant differences in the other outcomes.