Abdulmajeed Al Khathami

Background: Corneal astigmatism (CA) is a frequent refractive condition in patients undergoing cataract surgery. Although international data on CA prevalence exist, regional insights from Saudi Arabia remain scarce. Methods: This retrospective observational study analyzed preoperative biometric data from 537 eyes of 453 adult cataract surgery candidates at two ophthalmology centers in the Eastern Province of Saudi Arabia between 2022 and 2024. CA was assessed using optical biometry and Scheimplflug tomography. Astigmatism was categorized by magnitude and axis orientation: with-the-rule (WTR), against-the-rule (ATR), and oblique (OB). Demographic correlations were examined using appropriate statistical methods. Results: The mean CA was 1.08 ± 0.97 diopters (D), with 53.7% of eyes showing astigmatism between 0.51–1.50 D. CA ≥1.5 D was found in 29.6% of eyes, while high astigmatism (>3.0 D) was rare (4.48%). ATR astigmatism was the most prevalent overall, followed by WTR and OB. When stratified by age, both ATR and WTR showed their highest prevalence in the 60–69-year age group. A weak but statistically significant positive correlation was observed between age and CA magnitude ( r = 0.216, P P = 0.008), while anterior chamber depth showed no significant variation by astigmatism type ( P = 0.948). Conclusion: Corneal astigmatism is common among cataract surgery candidates in Saudi Arabia, with a substantial proportion having clinically significant levels requiring correction. Higher ATR values were detected in the older age groups compared with the younger. These findings underscore the need for standardized assessment protocols to guide astigmatism management and enhance refractive outcomes in cataract surgery.

Background: Occult macular pathology may limit visual recovery after cataract surgery but can remain undetected on routine clinical examination due to media opacity. Preoperative macular optical coherence tomography (OCT) improves detection of such abnormalities; however, its incremental prognostic value beyond routinely available clinical predictors remains uncertain. This study evaluated whether preoperative macular OCT provides additional predictive information for early (30– 120 day) postoperative visual acuity after phacoemulsification cataract surgery. Methods: This retrospective cohort study included consecutive eyes undergoing phacoemulsification for nuclear cataract at a tertiary eye hospital in Saudi Arabia between April 2023 and April 2025. Eligible eyes had documented preoperative and postoperative best-corrected visual acuity (BCVA) and a preoperative macular OCT scan of adequate quality. The primary outcome was postoperative BCVA measured within 30– 120 days after surgery. Multivariable analysis of covariance was used to identify predictors of postoperative BCVA. Incremental predictive value of OCT variables was assessed by comparing a base clinical model with an OCT-augmented model using changes in the coefficient of determination (R²), Akaike information criterion (AIC), and nested F-tests. Cluster-robust standard errors were applied to account for correlation between eyes from the same patient. Results: A total of 177 eyes were included, of which 57 (32%) demonstrated macular pathology on preoperative OCT. Eyes with macular pathology had worse preoperative BCVA but similar postoperative BCVA compared with eyes without pathology. In multivariable analysis, poorer preoperative BCVA (β = 0.224; P = 0.039) and older age (β = 0.090 per 10-year increase; P = 0.004) were independently associated with worse postoperative BCVA, whereas macular pathology was not. Adding OCT variables increased the model R² from 0.296 to 0.325 (ΔR² = 0.029; P = 0.029), indicating a statistically significant but modest improvement in predictive performance. Conclusion: Preoperative BCVA and age were the primary predictors of early postoperative visual acuity after phacoemulsification cataract surgery. Although macular OCT detected abnormalities in nearly one-third of eyes and provided a statistically significant improvement in predictive performance, the magnitude of this gain was modest, suggesting limited additional value for short-term visual outcome prediction beyond standard clinical factors.

Keratoconus is a progressive corneal disorder that often affects young individuals and can significantly impair visual function. Over the past two decades,

True divergence excess, a subtype of intermittent exotropia, presents with a greater exodeviation at distance than at nearby. Its management often requires tailored surgical strategies to address both distance and near deviations. A 9-year-old Saudi girl presented with intermittent right-eye exotropia. Prism and alternate cover test measurements revealed 30 prism diopters (PD) of exodeviation at distance and 12 PD at nearby. Cycloplegic refraction showed mild hyperopia. The accommodative convergence to accommodation ratio was within normal limits. No significant ocular or systemic comorbidities were present. The patient underwent bilateral lateral rectus recession (7 mm) to correct the distance deviation, combined with bilateral medial rectus Faden procedures to control near deviation. The surgery proceeded without complication. On postoperative Day 1, the patient achieved orthophoria at both distance and near. At the 3- and 6-month follow-ups, ocular alignment remained stable, with only a mild residual exotropia of 5 PD at distance without glasses. No diplopia or motility restrictions were reported. A combined surgical approach of bilateral lateral rectus recession and medial rectus Faden procedure can effectively manage true divergence excess in intermittent exotropia, yielding stable postoperative alignment. Individualized surgical planning remains essential for optimizing outcomes.

Blepharophimosis-Ptosis-Epicanthus Inversus Syndrome (BPES) is a rare congenital condition typically associated with mutations in the FOXL2 gene. It is characterized by eyelid malformations and, in some cases, premature ovarian insufficiency. Although visual complications such as astigmatism and amblyopia are well recognized, an association between BPES-like features and keratoconus has not been previously reported. We report a 41-year-old Saudi female presenting with progressive visual decline and congenital eyelid abnormalities. Clinical evaluation revealed features consistent with BPES, and corneal topography confirmed bilateral keratoconus. Genetic testing identified a homozygous pathogenic variant in the COLEC10 gene, with no FOXL2 mutations detected. A multidisciplinary management plan involving oculoplasty consult, corneal rehabilitation, and endocrine evaluation was implemented. This case represents a novel association between a COLEC10 mutation and a BPES-like phenotype with coexisting keratoconus. The findings suggest a potential genetic and mechanical basis for corneal ectasia in patients with congenital eyelid anomalies. The absence of FOXL2 involvement emphasizes the importance of broad genetic testing in atypical presentations. Routine corneal imaging and comprehensive genetic analysis should be considered in patients with syndromic eyelid malformations. This case expands the clinical spectrum of COLEC10-related disorders and supports the need for further research into its role in ocular development and corneal biomechanics.

Ankyloblepharon filiforme adnatum (AFA) is a rare congenital anomaly characterized by fine bands of tissue connecting the upper and lower eyelids, potentially obstructing vision if left untreated. We report a case of a preterm male neonate born at 33 weeks and 4 days of gestation via emergency cesarean section due to maternal preeclampsia. On examination, the infant had bilateral eyelid fusion consistent with AFA, confirmed by ophthalmologic evaluation. Surgical division of the adhesions was performed under general anesthesia with no complications. Postoperative recovery was uneventful, and follow-up confirmed clear corneas and normal ocular structures. This case highlights the importance of early recognition and prompt surgical management of AFA to prevent visual deprivation, particularly in preterm infants. It also underscores the need to assess for possible syndromic associations, although this case appeared isolated. Awareness of AFA among neonatologists and ophthalmologists can support timely diagnosis and intervention.

The demand for vitreoretinal surgery (VRS) specialists is increasing globally due to the rising prevalence of retinal diseases such as diabetic retinopathy and age-related macular degeneration. In Saudi Arabia, the burden of retinal diseases is particularly high, with diabetic retinopathy affecting about one-third of diabetic patients. Despite this, factors influencing ophthalmology trainees’ decisions to pursue VRS fellowship remain underexplored. This study aimed to identify the key factors shaping career decisions among ophthalmology trainees in Saudi Arabia. A cross-sectional study was conducted between July and December 2024, targeting senior ophthalmology residents and vitreoretinal surgery fellows across Saudi Arabia. A purposive sampling method was used, and data were collected via an online survey adapted from a validated tool and assessed for content validity. The survey explored exposure to VRS, research opportunities, mentorship, and career motivations using a 5-point Likert scale. Descriptive statistics and nonparametric Mann-Whitney U tests were applied. A total of 61 trainees participated, of whom 35 (57.4%) reported pursuing a VRS fellowship. Male trainees were significantly more likely to pursue VRS than females (88.6% vs. 46.2%, p < 0.001). Most VRS pursuers reported deciding during residency years R2–R3, and 40% had performed over 100 cataract procedures. Major motivators included strong interest in complex surgeries (74.3%), advanced technology (51.4%), and the perceived prestige of VRS (54.3%). Exposure to VRS, research opportunities, and program match success were significantly associated with career choice, while mentorship and work–life balance played a lesser role. The decision to pursue vitreoretinal surgery among ophthalmology trainees in Saudi Arabia is primarily influenced by early exposure, surgical complexity, and perceived prestige. Gender disparities remain evident, with male trainees more likely to enter VRS, partly due to limited female mentorship. Enhancing mentorship opportunities and fostering early exposure may help address these disparities and sustain interest in the subspecialty.

Background: Refractive errors, including myopia, hyperopia, and astigmatism, are a leading cause of visual impairment among children worldwide. In Saudi Arabia, the prevalence of these conditions among school-age children and adolescents remains poorly understood, with significant variations reported across studies. This systematic review and meta-analysis aimed to provide a comprehensive estimate of the pooled prevalence of refractive errors in this population and explored factors influencing their distribution. Methods: A systematic search of PubMed, Scopus, Web of Science, and ScienceDirect was conducted in accordance with PRISMA 2020 guidelines. Observational studies reporting the prevalence of refractive errors among Saudi school-aged children and adolescents were included. Data extraction and quality assessment were conducted using the Newcastle-Ottawa Scale. Pooled prevalence estimates with 95% confidence intervals (CIs) were calculated using a random-effects model, and heterogeneity was assessed with the I² statistic. Results: Nine studies including over 15,000 participants were analyzed. The pooled prevalence of myopia was 6.7% (95% CI: 3.0% to 14.2%), hyperopia was 3.6% (95% CI: 1.3% to 9.8%), and astigmatism was 7.7% (95% CI: 2.5% to 20.9%). Subgroup analysis revealed regional disparities, with the highest myopia prevalence reported in Taif (33.3%) and Bisha (22.5%), and the lowest in Medina (1.6%). Studies conducted after 2018 showed a significantly higher pooled myopia prevalence (16.4%, 95% CI: 8% to 30.5%) compared to those published before 2018 (3.3%, 95% CI: 1.4% to 7.5%) (p < 0.001). While studies using cycloplegic refraction reported a slightly higher myopia prevalence (7.2%, 95% CI: 4.7% to 11%) than those using non-cycloplegic methods (6.7%, 95% CI: 2.4% to 17.5%), the difference was not statistically significant (p = 0.9). No significant difference was observed between studies with smaller or larger sample sizes, although high heterogeneity persisted across all subgroups. Conclusion: Refractive errors, particularly astigmatism, represent a significant and growing public health issue among Saudi school-aged children and adolescents. The findings underscore the urgent need for standardized diagnostic protocols, including the use of cycloplegic refraction, and the implementation of school-based vision screening programs.

Background: Low vision (LV) is a significant public health challenge with profound effects on patients and their families. In Saudi Arabia, studies indicate a high prevalence of LV, yet low vision services (LVS) remain limited, with gaps in optometrist knowledge, training, and service accessibility. This study evaluates the current state of LV services, documents optometrist involvement, and identifies barriers to delivering LVS. Methods: A nationwide, cross-sectional study surveyed 275 optometrists using a validated, self-administered electronic questionnaire. Awareness, clinical practices, referral patterns, and perceived barriers were assessed. Multivariate logistic regression analyzed awareness levels and barriers, with statistical significance set at p< 0.05. Results: Moderate awareness of the WHO definition of LV was observed (70.1%), significantly higher among those with formal training (90.1%, p< 0.001). Only 36.4% provided LV services, primarily in the central region. Low vision cases constituted 1% of patient loads for most participants (44.4%). Key barriers included device unavailability (68.4%), insufficient training (65.8%), and high costs (50.9%). Diabetic retinopathy (70.9%), glaucoma (63.3%), and hereditary conditions (46.5%) were leading causes of LV. Conclusion: Critical gaps in LV care include insufficient awareness, uneven service distribution, and financial/training-related barriers. Enhancing education, improving affordability, and fostering multidisciplinary care are essential. Region-specific interventions are urgently needed to ensure equitable access to LVS across Saudi Arabia.

Endophthalmitis is a severe intraocular infection that can cause substantial visual impairment or blindness. Although it is an uncommon post-cataract surgery complication. In this case series, we present a group of patients who underwent surgery on the same day by the same surgeon. Our goal is to investigate the causes of this outbreak, explore the management strategies employed, and derive lessons learned to prevent future occurrences. This case series presents five immunocompetent patients who underwent uncomplicated cataract surgery at a single center and developed acute postoperative endophthalmitis. All patients presented with severe eye pain and decreased vision on the 2nd day post-surgery; one patient presented 15 days later. Following their surgeries, they were prescribed prednisone acetate and moxifloxacin, both to be taken every 2 h. Their visual acuity at presentation was light perception. Immediate vitreous tap and administration of intravitreal antibiotics. Despite these urgent interventions, the outcomes varied among the patients. In the short term, no significant improvement in visual acuity was noted; all patients continued to experience severely limited vision. The long-term consequences were grave: three of the five patients eventually underwent evisceration due to the severity of the infection and persistent inflammation. This underscores the aggressive nature of the infection and the challenges in managing such severe cases of endophthalmitis. This case series underscores the critical need for rigorous infection control protocols. By meticulously addressing these challenges, healthcare providers can enhance patient outcomes and significantly reduce the risk of future outbreaks in ophthalmic surgical settings.