Marys Medicine

Prime.edu.pk


„ EDITORIAL
Meibomian Gland Dysfunction (MGD)
„ OPHTHALMIC SECTION / ORIGINAL ARTICLES
Neuro-imaging Patterns of Isolated Ocular Motor Nerve Palsies in a Pakistani Cohort
A Study of Prevalence of Risk Factors in Patients with Non-
ArteriticAnterior Ischemic Optic Neuropathy (Na- Aion)
Dacryocystorhinostomy - is Endonasal Endoscopic Approach A Viable Option?
Ocular and systemic Complications of Intravitreal Bevacizumab (Avastin) therapy
Incidence of Intraocular Foreign Body in Penetrating Trauma presented to a
Tertiary Care Hospital of Khyber Pakhtun Khwa and its Visual Outcome
To Determine the Efficacy of Tattoo Ink in Changing the Color of Rabbit's Iris
Incidence of Hepatitis B & C among Admitted Eye Patients in Tertiary Care Hospital of Peshawar
Visual Outcome & Complications of Scleral-fixation Posterior Chamber Intraocular Lenses
Mir Ali Shah Aftab et al ---------------------------------------------------------------------------------------------------------------------------- 75 Prevalence and Density of Amblyopia in Strabismic Patients of School Age Children
Tuberous Sclerosis Complex
Association of Anemia with Diabetic Retinopathy in Patients with Type II Diabtese Mellitus
Intraocular Pressure Control after Cataract Extraction with Posterior Chamber
Intraocular Lens Implantation in Phacomorphic Glaucoma
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Causes of Low vision and Quality of Life after Rehabilitation in Children & Adults
Intraocular Pressure Control after The Efficacy of Limbal Based Conjunctival Flap
in Patients Undergoing Trabeculectomy with Intra-operative Mitomycin C
Normal Tension Glaucoma & Cerebral Ischemia / Brain Atrophy
Complications & Results of External Dacryocystorhinostomy in Chronic
Dacryocystitis without Intubation (Review of 107 Cases.)
Recurrence of Retinal Detachment after Silicone Oil Removal
Choroidal Melanoma in a Young Patient
„ GENERAL SECTION / ORIGINAL ARTICLES
Frequency of High Glasgow Blatchford Score & its One Month Mortality in
Patients presenting with Non-variceal Upper Gastrointestinal Bleeding
Meatal Mobilization Technique for Childhood Hypospadias Repair,
an Early Experience at Lady Reading Hospital, Peshawar
„ OPHTHALMOLOGY NOTEBOOK
Obituary- Forever Loved - Forever Missed ---------------------------------------------------------------------------------------- 123
Murree: The Queen of Mountains - A Shining Pearl of Pakistan (Malika-e-Kohsaar) ------------------------ 124
Ophthalmology Update Vol. 13. No. 2, April-June 2015




Meibomian Gland Dysfunction (MGD)
Meibomian Gland Dysfunction, also referred to face which can glide and spread the tear film from the as the posterior blepharitis, is a very common cause of tear meniscus in the lower conjunctival fornix, evenly a myriad of symptoms in the general population, par- over the cornea, giving it its polished appearance.4 Bac- ticularly after the age of 45 years which is often neglect- teria (staphlococci which are the normal flora of the ed and under-diagnosed by the ophthalmic fraternity.1 eyelid) invade the meibomian glands and produce li- Many ocular disorders, including evaporative dry eye, pases which break down the waxy esters in meibum blepharitis, sties, chalazia and ocular rosacea have been to short chain free fatty acids.5 These fatty acids are linked to abnormal function of the meibomian glands2. toxic to the ocular surface and causes its irritation. The Health professionals in the USA have now been alert- lack of waxy esters result in excessive evaporation of ed that MGD is a major contributing factor in ocular aqueous component of the tear film. The abnormally surface disease in at least 50 - 75% cases. According functioning glands may over secrete toxic meibum,
to the International Workshop on Meibomian Gland under secrete or get blocked, with underlying changes
Dysfunction in 2011, sponsored by the Tear Film and to the eye. Normally the meibum is in a fluid state at Ocular Surface Society, USA,2 there is a paradigm shift normal body temperature but these short chain fatty in the treatment of dry eyes. As a result of this report, acids clump together making the meibum viscid.6 This ophthalmologists are now evaluating the lids more thick, opaque secretion blocks the meibomian gland carefully, and more often when seeing patients with orifices, dries up and plugs them (seen in the top pic). dry-eye complaints. MGD has also been known to be When the gland becomes obstructed by thick, inspis- an important cause contact lens intolerance.3 sated secretion, the glandular epithelium degenerates Pathogenesis: Normally there are 40 meibomian
and stops functioning altogether, leading to minimal or glands in the upper lid and 20 in the lower. As the nonexistent production of meibum and loss of meibo- glands make meibum, it is normally pushed outward mian glands. The areas where the meibomian glands with each blink by the contraction of Riolan's muscle have atrophied appears as notches at the grey line (seen (pre-tarsal orbicularis) on to the surface of eyelids and in the bottom picture). Meibomian gland secretion is spreads over the lid margin making it a smooth sur- controlled by androgens, mainly testosterone. Its defi- Ophthalmology Update Vol. 13. No. 2, April-June 2015 ciency is particularly seen as a part of normal ageing v) Note the tear-film break up time: this gets reduced process. Hence, dry eye syndrome and MGD is more with worsening of the disease. Normal being >10 mm.
commonly seen in post-menopausal women.7 vi) Punctate keratopathy at the inferior limbus and in- MGD causes two problems: Firstly, eyelid inflamma-
ferior conjunctival staining due to irritation by toxic tion and secondly, excessive evaporation of tears and meibum at the lid margin.
consequently dry eyes. The tears become hyperosmoler vii) Transilluminate the tarsal plate by a pen-torch held which then stimulate corneal nerves resulting in ocular on the skin side of a fully everted lid to look for evi- irritation, dryness, tearing, redness, a foreign body sen- dence of atrophy, loss or degeneration of the meibomi- sation or intermittent blurring of vision. Examination: In every adult patient who has come to
viii) Check for aqueous deficiency of tear film with you with any eye complaint, try to assess for MGD and
Schirmer's 2 test.
look for the following first:
ix) Check the tear osmolarity if possible.
i) The lids may look normal but the lid margin has to be
x) In severe MGD, check lipid profile/ Blood Sugar.
everted a little bit and the meibomian gland orifices ex- Don't assume patients will voluntarily mention their
amined; normally the meibum is a clear secretion that symptoms. Be proactive, and ask every adult patient
flows easily out of the orifices with a tiny pressure at about ocular irritation and whether it is worse in the
the lid margin with a cotton-tip applicator. However, morning which points to MGD. A dry eye due to
an opaque secretion is abnormal. Or, the glands could aqueous deficiency is worse in the evening.
be completely blocked / plugged with thick white se- cretion which cannot be expressed with pressure on the a) Highest on the list is getting the patient to play an lid margin. Scarred and notched grey line indicates loss active role by scrubbing the lid margins with a baby of glands. Hence, there are different stages of meibo- shampoo twice a day to remove excess oil. mian gland disease.
b) Mobilize the oils 8 out of the lids onto the eye where ii) Grades of MGD:
you do want them. Achieve this through the use of lid Grade 0: Normal, no MGD: clear, thin secretion at the
compresses, which are believed to melt plugs com- gland orifices, squirts out of orifices with a little pres- posed of dried secretions blocking the gland orifice; sure on the lid margin. Apply hot fomentation to the lids with a hot towel to Grade 1: a viscid secretion flows out easily with mini-
melt the thick secretions/plugs and then expressing meibomian glands on a daily basis by massaging the Grade 2: an opaque secretion flows after exerting a lot
lower lid upwards and upper lid downwards with a finger or a Q-tip. this should be done 2-3 x per day. This Grade 3: gland orifices are plugged/capped and no se-
will not work in Grade 4 disease in whom there are no cretion flows or it comes out like a tooth-paste or a froth secretions at all due to atrophic glands. is present at the lid margins (due to saponification of c) Addressing the source of any inflammation; avoid fatty acids by bacterial lipases). aminoglycocides topically as they worsen MGD. Find Grade 4: atrophic/scarred gland orifices.
out and treat any allergies. Topical tetracycline eye NOTE: Toxic secretions cause an inferior conj / corneal
ointment massaged into the id margins twice per day. staining. If the ducts are blocked with thick meibum Systemic doxycycline9 can interfere with the lipases plugs, or have atrophied, then there will be no toxic se- produced by Staphlococci that break down the fatty cretions; however, if few ducts are open, then a little components to free fatty acids- a common regimen is bit of corneal staining will be there. Hence seeing cor- doxycycline 100 mg od or b.i.d. for four to six weeks, neal staining with open ducts is Grade 2 disease. See- in severe cases. An alternative is Azithromycin 500 mg ing corneal staining + majority of ducts being capped/ bid or 1 Gm od per week for 3 consecutive weeks. Simi- blocked is grade 3 disease. If grey line shows notching, larly, cyclosporin10 eye drops 0.5% - 0.75% twice a day then trans-illumination confirms atrophic glands at the have the same anti-inflammatory affect.
site of a notch (Grade 4 disease).
d) Neutralize toxic secretions with artificial tears; drops iii) Oily debris floating in tear film or foam present at during day and lubricating ointment at night.
the lid margins indicate hyper-secretion; the fatty acids e) Some patients are beyond the point of no return. undergo saponification by bacteria and produce toxic They don't have any glands left, or the ones they have aren't functioning. For them, heating and massaging iv) Look for Rosacea / recurrent chlazia which indicate won't do anything. They can be given Lipid-based ar- tificial tears.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 f) Oral Omega 3 Fatty acids11 to restore the balance be- blepharitis. Invest Ophthalmol Vis Sci.1986;27(4):486–491.
tween good and bad lipids.
Foulks GN. The correlation between the tear film lipid layer and dry eye disease. Surv Ophthalmol.2007;52(4):369–374.
g) Intra-ductal probing12 of blocked meibomian glands Sullivan DA, Sullivan BD, Evans JE. Androgen deficiency, mei- has been found to be effective in removing dried secre- bomian gland dysfunction, and evaporative dry eye. Ann New York Academy Sciences 2002;966:211-222 Olson MC, Korb DR, Greiner JV. Increase in tear film lipid Recommendation: MGD is a very common eye prob- layer thickness following treatment with warm compresses lem; try to look for it in every adult who presents at the in patients with meibomian gland dysfunction. Eye Contact ophthalmic clinic. Every patient should be specifically 9. Dougherty JM, McCulley JP, Silvany RE, Meyer DR. The role of asked for symptoms of ocular irritation. An eye exami- tetracycline in chronic blepharitis. Inhibition of lipase production nation should commence from the lids.
in staphylococci. Invest Ophthalmol Vis Sci. 1991;32(11):2970– It is important to familiarize with the normal meibo- 10. Rubin M, Rao SN. Efficacy of topical cyclosporine 0.05% mian secretion by examining the lids of teenagers first in the treatment of posterior blepharitis. J Ocul Pharmacol and trying to squirt out meibum with a gentle squeeze Ther. 2006;22(1):47–53. on the lid margin. 11. Macsai MS. The role of omega-3 dietary supplementation in blepharitis and meibomian gland dysfunction (an AOS the- sis) Trans Am Ophthalmol Soc. 2008;106:336–356.
Bron AJ, Tiffany JM. The contribution of meibomian disease to 12. Maskin SL. Intraductal meibomian gland probing relieves dry eye. Ocul Surf. 2004;2(2):149–165.
symptoms of obstructive meibomian gland dysfunction. Cor- The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the Interna- tional Dry Eye WorkShop (2007) Ocul Surf. 2007;5(2):75–92. Korb DR, Henriquez AS. Meibomian gland dysfunction and Dr. Sameera Irfan, FRCS
contact lens intolerance. J Am Optom Assoc. 1980;51(3):243– Consultant Oculoplastic Surgeon & Strabismologist Mughal Eye Trust Hospital, Lahore, Pakistan McCulley JP, Shine WE. The lipid layer of tears: dependent on meibomian gland function. Exp Eye Res 2004;78:361-5.
Website: www.sameerairfan.com 5. Dougherty JM, McCulley JP. Bacterial lipases and chronic Cell: 03364500901 OPHTHALMOLOGICAL SOCIETY OF PAKISTAN
(Federal Branch, Islamabad)
Following members have been elected as the office bearers of the Ophthalmological Society of Pakistan, Federal Branch, in a recent election held in Islamabad for the year 2015-16.
President
Dr. Waheed Afzal
President Elect
Prof Farooq Afzal
General Secretary
Dr Shahzad Saeed
Treasurer
Prof Nadeem Qureshi
Joint Secretary
Prof B. A. Naeem
Executive Council:
Prof. Jahangir Akhter, Dr. Izzat Ali Khan, Prof. Brig. Amer Yaqub, Prof. Imran Azam Butt Prof. Mazhar Ishaq, Prof. Syed Imtiaz Ali, Prof. Wajid Ali Khan, Prof. Naqaish Sadiq Prof. Shakaib Anwar, Dr. Tariq Mirza, Dr. Amir Israr, Dr Intisar-Ul-Haq, Lt. Gen (R) M K Akbar, Dr. Naeem Qadir, Dr. Shahzad Iftikhar, Dr. Ali Raza, Dr. Javed Malik, Dr. Mazhar Qayyum Ophthalmology Update Vol. 13. No. 2, April-June 2015


Neuro-imaging Patterns of Isolated
Ocular Motor Nerve Palsies in a Pakistani Cohort
Tayyaba Gul Malik FCPS1, Prof. Khalid Farooq FCPS (Diagnostic Radiology)2 Muhammad Khalil FCPS3 Objective: To determine neuro-imaging patterns of ocular motor nerve palsies in a Pakistani cohort and to compare with
other populations.
Study Design: Descriptive, retrospective study.
Study period: 2010 to 2014
Subjects and settings: 50 Patients of ocular motor nerve palsies from two different centers of Lahore were included in
the study. History charts and neuro-imaging reports were reviewed. The data considered for the study was age, sex, ocular manifestations, neuro-ophthalmological findings and imaging reports (CT scans, MRI, MRA and MRV).
Results: Female to male ratio was 1.6:1. Age ranged from 13 years to 74 years (average 44.18). 66% (n=33) patients
had isolated sixth nerve palsy and 34% (n= 17) had isolated third nerve palsy. None of our patients had fourth nerve palsy. 42% patients had normal neuro-imaging. Sinusitis and brain infarcts were commonest cause of third nerve palsy while demyelination was more common in patients with sixth nerve palsy. Other neuro-etiologies were space-occupying lesions, parasellar tumours, multiple sclerosis, aneurysm and meningitis.
Conclusion: Third nerve palsy is the commonest ocular motor nerve palsy. There are certain cases where neuro-imaging
shows normal scans and the cause of palsy remains undetermined.
Key words: Ocular motor nerve palsy, trochlear palsy, oculomotor palsy, abducent palsy, Parasellar tumours, neuro-imaging.
Very interestingly, idiopathic palsies constitute a large Ocular motor nerves are comprised of Oculomo- percentage in clinical practice. Acoustic neuroma, basal tor (supplying Medial Rectus, Superior Rectus, Inferior skull fractures, naso-pharyngeal tumours and raised Rectus, Inferior Oblique), Trochlear (innervating Supe- intracranial pressures are culprits of sixth nerve pathol- rior Oblique) and Abducent (nerve to the Lateral Rec- ogies2. Cavernous sinus pathologies give rise to multi- tus). Ocular motor nerve palsies are either supra nucle- ple cranial nerve palsies (oculomotor, trochlear, abdu- ar or infra nuclear. Associated neurological signs and cent, ophthalmic and maxillary divisions of trigeminal symptoms help us determine the site of lesion. Fascicu- nerves). This study reviews the neuro-imaging patterns lar palsies of third nerve are associated with different of ocular motor nerve palsies in a selected group of pa- syndromes (Benedikt, Weber, Nothnagel and Claude). tients from two tertiary care hospitals of Pakistan.
Similarly, fascicular lesions of sixth nerve are associat- SUBJECTS AND METHODS
ed with Foville and Millard-Gubler syndromes.1 Fourth It was a descriptive retrospective study. 50 pa- nerve palsies are usually congenital in nature. tients with acquired isolated Ocular motor nerve (Oc- Different causes of isolated nerve palsies are men- ulomotor, Trochlear and Abducent) palsies were se- tioned in literature. These include vascular diseases lected (from two centers of Lahore City). Study period like Diabetes and Hypertension. In Oculomotor palsy spanned over 2010 to 2014. associated with Diabetes and Hypertension, pupils Inclusion criteria:
are usually spared. Aneurysms and trauma are other • Patients with acquired isolated third, fourth or important causes of isolated nerve palsies. Tumours, sixth cranial nerve palsies neurosyphilis and Giant cell arteritis are rare causes. • Patients whose, complete clinical and radiological data was available.
1Associate Professor of Ophthalmology, 2Professor, Department of Radiology, 3Associate Professor of Ophthalmology, Lahore Medical and Dental College, Tulspura, North Canal Bank,Canal Road, Lahore • Patients with multiple cranial nerve palsies • Patients with incomplete clinical and imaging data Correspondence: Dr. Tayyaba Gul Malik FCPS, Associate Professor We reviewed clinical and imaging charts of se- of Ophthalmology, Lahore Medical and Dental College, Lahore E.mail: tayyabam@yahoo.com, Mob: 0300-4217998 lected patients and medical records were analyzed. Clinical data included history, visual acuity, color vi- Received: January 2015 Accepted: February 2015 sion and slit lamp examination. Special attention was Ophthalmology Update Vol. 13. No. 2, April-June 2015




Neuro-imaging Patterns of Isolated Ocular Motor Nerve Palsies in a Pakistani Cohort given to pupillary reactions, extra ocular movements, aging. 11 patients with normal scans had uncontrolled cover/un-cover tests and fundoscopy. Neuro-imaging diabetes. Details of neurological scans are shown in tests included Computerized tomography with both graphs 1,2 and 3. The commonest etiologies of third plain and post contrast images, MRI with T2 and T1 nerve palsy (with positive neuro-imaging results) were weighted plain and post contrast images, (Gd-DTPA brainstem infarcts and maxillary sinusitis while demy- used for post contrast component), magnetic resonance elinating disease was major cause of sixth nerve palsy. arteriography and venography. Data was compiled, re- sults deduced and descriptive statistical analysis was Fifty patients, 31 females and 19 males (female: male ratio, 1.6:1) were included in the study. Age ranged from 13 years to 74 years (mean 44.18 years). 66 % (n= 33) patients had isolated third nerve palsy and 34% (n= 17) had isolated sixth nerve palsy. None of our patients had fourth nerve palsy. Headache (34%, n= 17) and diplopia were the commonest symptoms at presen- tation. 58% of the patients had right sided nerve palsies and 42% had left sided involvement. None of our pa- tients had bilateral palsies. Normal imaging scans were seen in 44% patients. 13 out of 33 (39.39%) patients with Graph-3: Comparison of Oculomotor and Abducent nerve palsies
oculomotor nerve palsy had negative scans. The pa- tients with normal MRI and third nerve palsy had nor- mal pupils. 9 out of 17 (52.9%) patients with Abducent nerve palsy showed no positive findings on neuro-im- Figure-1: Solid homogeneously enhancing extra axial mass
(meningioma) with significant mass effect on left side of mid rain
Graph-1: Neuro-imaging in patients of third nerve palsy
Figure-2: Right para sellar meningioma (T2 and T1) coronal /axial
post contrast images showing significant mass effect on right
Graph-2: Neuroetiology of sixth nerve palsy
cavernous sinus, pituitary stalk and optic chiasm.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Neuro-imaging Patterns of Isolated Ocular Motor Nerve Palsies in a Pakistani Cohort Parasellar meningioma pressing on the cavernous sinus es. Our ability to collect detailed information was lim- was the commonest space occupying lesion leading to ited by the retrospective study and we had to rely on oculomotor ( 6%, n= 2/33) and abducent nerve palsies the available data. But this study can provide grounds (5.88, n= 1/17). Only one case of Acoustic neuroma had on which prospective follow-up studies can be done. sixth nerve palsy. The patient had developed palsy as a complication of neurosurgery for Acoustic neuroma. Third nerve palsy is the commonest ocular motor One of our patients with third nerve palsy had multiple nerve palsy. There are certain cases where neuro-imag- tuberculomas in parasellar region.
ing shows normal scans and the cause of palsy remains Out of twelve pairs of cranial nerves, three pairs supply extra ocular muscles of eyeball. Diabetes, Hy- pituitary tumour. 2007;14(12):1158-62. pertension, aneurysms, trauma and brain tumours are Hung CH, Chang KH, Chu CC,et al. Painful ophthalmoplegia the most commonest causes of these nerve palsies. There with normal cranial imaging. BMC Neurol. 2014; 14: 7 Chiu EK, Nicholas JW: Sellar lesions and visual loss: key are certain cases where cause cannot be found and they concepts in neuro-ophthalmology. Expert Rev Anticancer are considered under the heading of idiopathic. In this Ther 2006; 6(9):23-29 particular study third nerve palsy was the common- Newman NJ, et al. Pain in Ischemic Ocu- est among all ocular motor palsies. It was consistent with the findings of Kim et al,3 4 and F and VIS group. Prevalence of ocular motor cranial Chiu EK5 Contrary to that, many other researchers had nerve palsy and associations following stroke. Eye (Lond). Jul 2011; 25(7): 881–887. preponderance of sixth nerve palsy in their studies.4,5,6 Zafar A, Irfan M. Lateral rectus palsy: An important sign in di- Male to female ratio was 1.6:1 in a study by Shawn C in agnosing tuberculous meningitis. KUST Med J 2011; 3(1): 10-14.
his cohort with an average age of 66.9 years.4 The ratio Kumar MP, Vivekanand U, Umakanth S, Yashodhara BM. A was reverse in our study (1:1.6) study of etiology and prognosis of oculomotor nerve paralysis. Edorium J Neurol 2014;1:1–8.
In this particular study, 22% patients (n=11) were Rucker CW. The causes of paralysis of the third, fourth and idiopathic. It was very much similar to the figures sixth cranial nerves. Am J Ophthalmol 1966;61(5 Pt 2):1293–8. given by Kumar9, Rucker et al.10 And Krishna et al.11 Krishna AG, Mehkri MB. India Neurol 1973 Suppl. IV. Vol 20: While this percentage was quite high . The incidence of ocular palsy associated with pituitary tu- mors is reported to be between 4.6 and 32%.11 We had May;103(1):10-5. 11. Greenman Y, Stern N. Non-functioning pituitary adenomas. parasellar meningiomas leading to ocular motor palsy Best Practice & Research Clinical Endocrinology & Metabo- but none of our patients had pituitary adenoma. Later- lism 2009, 23:625-638. ality of palsies is also interesting. 52% of our patients 12. S, Noronha VO, RA. The diagnostic had right sided palsy which was very much consistent yield of neuroimaging in sixth nerve palsy - Sankara Nethra- laya Abducens Palsy Study (SNAPS): Report1. Indian J Oph- with an earlier study.12 Headache and diplopia were thalmol. Oct 2014; 62(10): 1008–1012. the commonest presenting complaints of ocular motor 13. MA, GS. Isolated Third, Fourth palsies in our study similar to earlier researchers.13 and Sixth Cranial Nerve Palsies From Presumed Microvascular Versus Other Causes: A There are many cases where MRI or other arterial and venous scans show negative results. Controversy 14. Patel SV, Mutyala S, Leske DA, Hodge DO, Holmes JM. Inci- still exists whether to perform scans in every patient dence, associations, and evaluation of sixth nerve palsy using a population-based method. Ophthalmology. 2004;111:369–75.
with isolated ocular motor nerve palsy. One school of 15. , . Neuroimaging and thought in the absence of other neurological signs is to acute ocular motor mononeuropathies: a prospective study. have a close follow up of the patient. If neurological 2011;129(3):301-5. findings develop, neuro-imaging should be performed 16. ,,, et al. MRI in isolated sixth nerve palsies. 2001 Sep;43(9):742-5. 16,17. Others have suggested to perform neurological im- 17. Kanski JJ. Neuro-ophthalmology. In: Clinical Ophthalmology: aging in all patients even if there is evidence of vascu- a systematic approach. 7th Edi. Elsevier Butterworth Heine- lopathy18. In fact, every patient should be thoroughly mann; 2011. p 1055 18. Kanski JJ. Neuro-ophthalmology. In: Clinical Ophthalmology: investigated and neuro-imaging should be performed a systematic approach. 7th Edi. Elsevier Butterworth Heine- depending upon history, age and examination find- mann; 2011. p 1063 pituitary tumour. 2007;14(12):1158-62. This study has certain limitations. Small sample 20. Hung CH, Chang KH, Chu CC,et al. Painful ophthalmoplegia size could be the cause of absent fourth nerve palsy cas- with normal cranial imaging. BMC Neurol. 2014; 14: 7 21. Chiu EK, Nicholas JW: Sellar lesions and visual loss: key Ophthalmology Update Vol. 13. No. 2, April-June 2015 Neuro-imaging Patterns of Isolated Ocular Motor Nerve Palsies in a Pakistani Cohort concepts in neuro-ophthalmology. Expert Rev Anticancer 29. Greenman Y, Stern N. Non-functioning pituitary adenomas. Ther 2006; 6(9):23-29 Best Practice & Research Clinical Endocrinology & Metabo- lism 2009, 23:625-638. 30. S, RA. The diagnostic yield of neuroimaging in sixth nerve palsy - Sankara Nethra- 23. F and VIS group. Prevalence of ocular motor cranial laya Abducens Palsy Study (SNAPS): Report1. Indian J Oph- nerve palsy and associations following stroke. Eye (Lond). Jul thalmol. Oct 2014; 62(10): 1008–1012. 2011; 25(7): 881–887. 31. MA, GS. Isolated Third, Fourth 24. Zafar A, Irfan M. Lateral rectus palsy: An important sign in di- and Sixth Cranial Nerve Palsies From Presumed Microvascular agnosing tuberculous meningitis. KUST Med J 2011; 3(1): 10-14.
Versus Other Causes: A 25. Kumar MP, Vivekanand U, Umakanth S, Yashodhara BM. A study of etiology and prognosis of oculomotor nerve paralysis. 32. Patel SV, Mutyala S, Leske DA, Hodge DO, Holmes JM. Inci- Edorium J Neurol 2014;1:1–8.
dence, associations, and evaluation of sixth nerve palsy using 26. Rucker CW. The causes of paralysis of the third, fourth and a population-based method. Ophthalmology. 2004;111:369–75.
sixth cranial nerves. Am J Ophthalmol 1966;61(5 Pt 2):1293–8. 27. Krishna AG, Mehkri MB. India Neurol 1973 Suppl. IV. Vol 20: acute ocular motor mononeuropathies: a prospective study. 2011;129(3):301-5. 34. ,, et al. MRI in isolated May;103(1):10-5. sixth nerve palsies. 2001 Sep;43(9):742-5. 40 years with no co-morbids with the presentation as in pictures. It started
a year back with recurrent redness and swellings. Now this picture for last
20 days in RE and beginings in LE as well.
DD. cavernous sinus thrombosis, Chemosis, bleeding orbital varices
Curtesy: Dr. Muhammad Rashad Qamar RaoFCPS, FRCSAssociate Professor of OphthalmologyQAMC, Bahawalpur, PakistanE-mail: drrashadqr@yahoo.com Ophthalmology Update Vol. 13. No. 2, April-June 2015 A Study of Prevalence of Risk Factors in
Patients with Non-Arteritic Anterior Ischemic
Optic Neuropathy (Na- Aion)
Akhunzada M. Aftab Akhunzada Muhammad Aftab FCPS1, Misbah Durrani FCPS2, Asif MBBS3 Awais Rauf MBBS4, Farzana MBBS5, Prof. Mustafaf Iqbal FRCS, FRCOphth6 Purpose: To estimate prevalence of risk factors in patients diagnosed with Non- Arteritic Anterior Ischemic Optic Neuropath
(NA- AION).
Methods: This was a retrospective chart review of patients admitted and diagnosed as NA- AION. Patients with other optic
nerve diseases like Diabetic Papillitis and patients with signs of Arteritic Anterior Ischemic Optic Neuropathy (like raised ESR and CRP) were excluded from the study. Hematological investigations, clinical data like fundus photos and radiological investigations were evaluated to detect associated risk factors.
Results: A total of 24 subjects were included in the study. Total number of males was 15 (62.5%), while 9 (37.5%) were
females. Mean age at presentation was 57 years (Range 19- 60 years). Total number of diabetics alone were 2 (8.3%), Hypertensive were only 3 patients(12.5%) while 14 (58.3%) suffered both from diabetes and hypertension. 5 (20.8%) were neither diabetics nor hypertensive. Patients with hyper lipidemia were 10 (41.6 %). Echocardiography revealed abnormali- ties including diastolic dysfunction (DF) in 15 (62.5%), mitral regurgitation (MR) in 3 (12.5%), aortic regurgitation (AR) in 2 (8.3%), mitral valve prolapse (MVP) in 1 (4%), while 8 (34%) patients had a normal study. One (4%) patient was found to be Protein C deficient, 1 (4%) was Protein S deficient and 1 (4%) patient had both Protein C and S deficiency. Small optic discs were seen in 18 (75%) patients.
Conclusion: Diabetes, Hypertension and a small disc size are the most common risk factors associated with NA-AION in
our setup.
Key Words: Non Arteritic Anterior Ischemic Optic Neuropathy, Diabetes Mellitus, Hypertension, Sleep Apnea
segmental supply to the optic nerve head and physi- Anterior ischemic optic neuropathy is of two ologically acts as end arteries.3 types; Arteritic and Non Arteritic. Arteritic type is as- Patients usually present with sudden painless loss sociated with giant cell arteritis. It is associated with of vision in one eye, commonly noticed after waken- raised inflammatory markers like erythrocyte sedimen- ing from sleep. Some patients may present with slight tation rate (ESR) and C - reactive protein levels. Non blurring of vision and a near normal visual acuity is Arteritic Anterior Ischemic Optic Neuropathy is a mul- recorded in them. Several studies have shown high ti- factorial, acute optic neuropathy. It is the most com- prevalence of multiple risk factors. These may be con- mon optic neuropathy in patients aged over 50 years sidered as local or systemic factors and is the second most common cause of optic nerve related permanent visual loss in adults after glaucoma.1 • Diabetes Mellitus The pathogenesis of NA- AION involves acute ischem- • Hyperlipidemia ic infarction of the optic nerve head, which is supplied • Ischemic heart disease by the short posterior cilliary arteries (SPAC).2 Despite • Nocturnal hypotension the controversies regarding the distributary variations and characteristics of SPCA anastomoses around the • Absent or small cup in optic disc, and many ON head, it has been proved, that, this circle provides Some studies have shown intrinsic disorders of 1Registrar Eye A Unit Department of Ophthalmology, Khyber Teaching regulation of coagulation as an additional risk factor.2, 5 Hospital, Peshawar, 2Assistant Professor of Radiology, Bacha Khan Medical College & Mardan Medical Complex, 3,4,5,Traniee Medical The purpose of this study was to evaluate the incidence Officer. A Unit Department of Ophthalmology, Khyber Teaching of these risk factors in patients admitted to Eye A Unit, Hospital, Peshawar, 6Prof. & Head of Ophthalmology, Khyber Khyber Teaching Hospital, diagnosed with NA-AION.
Teaching Hospital, Peshawar. Correspondence: Dr. Akhunzada Muhammad Aftab c/o Prof. Dr. This retrospective chart review study was con- Muhammad Ibrar, Department of Botany, University of Peshawar, ducted on patients previously admitted in Eye A Unit of Khyber Teaching Hospital. Diagnosis of NA- AION Received: November 2014 Accepted: December 2014 was made considering the following criteria: Financial Disclosure: There has been no financial interest involved • Positive clinical history of sudden painless visual in this study loss/ blurring of vision.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 A Study of Prevalence of Risk Factors in Patients with Non-Arteritic Anterior Ischemic Optic Neuropathy (Na- Aion) • Presence of risk factors.
and APTT levels within normal range.
• Reduced/ near normal visual acuity.
One (4%) patient was found to be protein C defi- • Presence of relative afferent pupillary defect cient, 1 (4%) was Protein S deficient and 1 (4%) patient had both protein C and S deficiency in our study. One • Diffuse or sectorial optic nerve head edema. patient was suffering from hepatitis C and was taking • Central and (or) altitudinal field defect on Hum- interferon treatment. Fundus photographs revealed 18 phrey's visual field.
(75%) patients in our study to have small discs with • Normal ESR and CRP little or no cup. These discs are commonly referred to All the available records including history sheets, as "disc at risk". Carotid doppler imaging revealed 7 hematological investigations, ophthalmic examination, (29%) patients to be having atheromatous plaques in fundus photos, visual fields and radiological investiga- the carotid arteries. None of these patients had more tions were reviewed. We evaluated history of onset and than 70% stenosis. Echocardiography revealed ab- duration of loss of vision. Duration of systemic disease normalities including diastolic dysfunction (DF) in 15 like diabetes and (or) hypertension was considered. (62.5%), mitral regurg (MR) in 3 (12.5%), aortic regurg Also inquiry from the patient and (or) partner regard- (AR) in 2 (8.3%), mitral valve prolapse (MVP) in 1 (4%), ing noticing symptoms of sleep apnea was also evalu- while 8 (34%) patients had a normal study.
ated. Hematological tests reviewed included complete blood count (CBC), ESR, CRP levels, glycosylated hemoglobin (HbA1c) levels, fasting lipid profile, renal function tests (RFT), prothrombin time (PT) and acti- vated partial thromboplastin time (APTT), homocyst- eine levels, protein -C and -S levels. Fundus photos were evaluated for size of the disc and size of the cup. Radiological investigations which were analyzed in- cluded carotid doppler, echocardiography and ECG.
In this study, 24 patients were included.Total number of males was 15 (62.5%), while 9 (37.5%) were females. Mean age at presentation was 57 years (Rang- ing from 19- 60 years). All (100%) had a positive clini- cal history of sudden painless loss/ blurring of vision in the affected eye and presented within 10 weeks of NA- AION is the most common type of ischemic optic neuropathy. It may or may not be present with onset of symptoms (Range 3 days to 10 weeks). Almost decrease in visual acuity and is usually associated with half the study patients (13), reported to have noticed visual field defects, respecting the horizontal mid line. vision loss upon wakening up in the morning. Only The characteristic clinical features and the associated one (4%) patient's history was positive for sleep ap- risk factors are important in making the diagnosis as nea. 14 (58.3%) patients suffered both from diabetes NA-AION is often misdiagnosed as optic neuritis or in and hypertension. 2 patients (8.3%) were having only case of diabetics as diabetic papillopathy or even prolif- diabetes and 3 patients (12.5%) were diagnosed hyper- erative diabetic retinopathy. It must also be emphasized tensive patients. 5 (20.8%) patients were neither diabet- that two large studies have looked into the natural his- ics nor hypertensive. Mean duration of diabetes was tory of NA- AION and have reported a spontaneous 7 years (Range 6 months to 15 years). Mean duration improvement in 41%- 43% of eyes.6, 7 of hyper tension was 5 years (Ranging from 2 months The most common presenting feature of NA- to 20 years). All (100%) patients had normal CBC, ESR AION is noticing sudden loss of vision upon awaken- and CRP levels. All diabetics had raised HbA1c levels ing. This finding has been reported by 62% patients (mean = 8.7%). 10 out of 17 hypertensive patients in to- in our study. Similar incidence of discovering loss of tal had raised blood pressure recordings. Patients with vision upon awakening was reported in 73% cases [8].
hyper lipidemia were 10 (41.6%).3 patients had raised Regarding visual field defects, a large study has shown cholesterol, 3 had raised triglycerides while 4 patients inferior nasal defects to be the most common types of had both cholesterol and triglyceride levels above nor- defects.9 In this study, we concluded that the most com- mon risk factors in our study population for NA-AION All 24 (100%) patients had renal function tests, PT were hypertension (70%) and diabetes (66%) followed Ophthalmology Update Vol. 13. No. 2, April-June 2015 A Study of Prevalence of Risk Factors in Patients with Non-Arteritic Anterior Ischemic Optic Neuropathy (Na- Aion) by hyperlipidemia (42%). Another study conducted at Hiraoka M, Inoue K, Ninomiya T, et al. Ischaemia in the Singapore,10 the most common risk factor were found Zinn–Haller circle and glaucomatous optic neuropathy in ma- to be hypertension (60%) followed by hyperlipidemia caque monkeys. Br J Ophthalmol.2012. doi:10.1136/bjophthal- (51%) and diabetes (49%). In the Ischemic Optic Neu- Hayreh SS.Ischemic optic neuropathies - where are we ropathy Decompression Trial,11 conducted at 25 US now?Graefes Arch ClinExpOphthalmol. 2013 Aug;251(8):1873- clinical centers, hypertension (47%) was the most com- Acheson F J, Sanders M D. Coagulation Abnormalities in Is- mon risk factor, followed by diabetes (24%).
chemic Optic Neuropathies. Eye. 1994;8:89-92 Another study conducted in Malaysia by a. Bawa- Cullen JF, Chung SHR. Non-arteritic anterior ischaemic optic zir et al on 18 patients (20 eyes) at the Hospital Univer- neuropathy (NA-AION): Outcome for visual acuity and visual sity Sains Malaysia from January 2005 until December fielddefects, the Singapore scene 2. Singapore Med J 2012; 53(2) 2009 revealed hypertension (55%) and diabetes in 44% Ischemic Optic Neuropathy Decompression Trial Research patients of NA-AION.12 These studies conducted on Group. Characteristics of patients with nonarteritic anterior Asian populations are parallel with our findings.
ischemic optic neuropathy eligible for the Ischemic Optic Regarding treatment of NA- AION, multiple ther- Neuropathy DecompressionTrial. Arch Ophthalmol. 1996; apies have been tried including management of risk Bawazir A, Gharebaghi R, Hussein A, Wan Hitam WH. Non- factors, optic nerve sheath decompression, systemic arteritic anterior ischaemic optic neuropathy in Malaysia: a 5 steroids, Aspirin, Intravitreal triamcinolone and intra- years review.Int J Ophthalmol. 2011;4(3):272-274 Hayreh SS, Zimmerman B. Visual field abnormalities in non- arteritic anterior ischemic optic neuropathy: Their pattern and prevalence at initial examination. Arch Ophthalmol. In this study we concluded that the most common risk factors for NA- AION in our population are hyper- 10. Cullen JF, Chung SHR. Non-arteritic anterior ischaemic optic neuropathy (NA-AION): Outcome for visual acuity and visual tension followed by diabetes.
field defects, the Singapore scene 2. Singapore Med J 2012; 53(2) Arnold AC. Ischemic optic neuropathy. In: Miller NR, New- 11. Ischemic Optic Neuropathy Decompression Trial Research man NJ, Biousse V, Kerrison JB. Walsh & Hoyt's Clinical Neu- Group. Characteristics of patients with nonarteritic anterior ro-Ophthalmology, 6th ed, Vol 1. Baltimore : Lippincott Wil- ischemic optic neuropathy eligible for the Ischemic Optic liams & Wilkins,2005:349-84 Neuropathy Decompression Trial. Arch Ophthalmol. 1996; Felekis T1, Kolaitis NI, Kitsos G, Vartholomatos G, Bourantas KL, Asproudis I.Thrombophilic risk factors in the pathogenesis 12. Bawazir A, Gharebaghi R, Hussein A, Wan Hitam WH. Non- of non-arteritic anterior ischemic optic neuropathy patients.
arteritic anteriorischaemic optic neuropathy in Malaysia: a 5 Graefes Arch ClinExpOphthalmol. 2010 Jun;248(6):877-84.
years review. Int J Ophthalmol. 2011;4(3):272-274 The World Glaucoma Congress
is being held from 6-9 June 2015 in Hong Kong
While the preparations for 2nd IGCP are in full swing, Pakistan Glaucoma Society like to share with a good news. Two symposia on Glaucoma Diagnosis and Management that we had submitted in the scientific programme of World Glaucoma Congress have been accepted. Prof Nadeem Hafeez Butt and Prof Syed Imtiaz Ali have received invitations as speakers and to chair a session. It is hoped that it will strengthen our relationship with World Glaucoma Association and in future to hold World Glaucoma Congress in Pakistan, as these events are landmarks and turning points for the development of subspecialty in the country and region.
Prof. Nadeem Hafeez Butt, FRCS
Executive Vice President
Ophthalmological Society of Pakistan &
President Elect, SAARC Academy of Ophthalmology
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Dacryocystorhinostomy - is Endonasal
Endoscopic Approach A Viable Option?
Khawaja Khalid Shoaib FCPS, FRCS1, Sabih uddin Ahmed FCPS, FRCS2 Iftikhar Aslam FCPS3, Syed Nadeem ul Haq FCPS4 ABSTRACT:
Objective: To analyze the per operative problems, post operative complications and success rate of dacryocystorhinosto-
mies performed by endoscopic endonasal approach (endo DCR).
Study design: Quasi - experimental study
Place and duration of study: CMH Kharian and Mardan, from Jan 2008 to Dec 2011
Material and Method: In the initial ten cases, only nasal packing with 2 % xylocaine with adrenaline was done and kept for
fifteen minutes. In the next ten cases, after packing, injection of the same solution was given at sac area and middle turbi- nate. Packing was done again for ten minutes. In rest of the cases, after packing, cautery was done instead of the injection. In all the procedures, silastic intubation and application of Mitomycin C 0.5 mg/ml for ten minutes was done.
Results: A total of 35 endo DCR were done in 34 patients under general anesthesia. 3 (9%) were males and 31 (91 %) were
females. Age ranged from three years to sixty three years (mean 42 + 15). Follow up ranged from 4 to 11 months (mean 6.5 + 2.5). Problems during the operation included moderate bleeding obscuring view during six (17%), difficulty in localization of sac area in five (14 %), mild bleeding on first post operative day after three (9%), nasal mucosal adhesions after one (3 %) and persistent watering after six (17 %) requiring re operation with endonasal endoscopy. Success rate was 83 % after first operation and 94% after the endo procedure.
Conclusion: Complications encountered during and following endo DCR can be managed. The procedure has a good
success rate.
Keywords: Dacryocystorhinostomy, endoscopic DCR, endonasal DCR
chronic dacryocystitis or mucocele and obstruction at Dacryocystorhinostomy (DCR) by external(ext) or beyond common canaliculus. Cases having punctual approach is a gold standard for the management of stenosis or eversion and those having canalicular ob- obstruction of lacrimal passages beyond the common struction, were excluded from the study.
canaliculus. However internal approach is also becom- ing popular now. Through the nose endoscopic (Endo) DCR can be done either mechanically or with different types of lasers. Advantages during the procedure in- clude magnified view, bright focal illumination, pro- jection on closed circuit TV (Fig 1), option of recording and no bleeding from skin and orbicularis while post operative advantages are decreased pain and reduced recovery time. Present study was carried out to find out the problems encountered during endo DCR, post op complications and the overall success rate.
MATERIAL AND METHOD
This quasi experimental study was carried out at eye departments of CMH Kharian and Mardan from Jan 2008 to Dec 2011. A total of 35 endo DCR were done in 34 patients. Probing and sac syringing was done in all the cases presenting with watering of eyes and no cause of excessive production of the tears. Inclusion cri-
teria for the study were watering, purulent discharge,
Fig-1: Endonasal DCR with endoscope, camera and
projection on monitor
1Eye Specialist, CMH Kharian. 2Eye Specialist, CMH Rawalpindi 3Eye Specialists, Lahore. 4RMI, Peshawar. A 30 degree nasal endoscope was used and pack- Correspondence: Col. Khawaja Khalid Shoaib, Eye Department, ing with ribbon gauze (soaked in 2% xylocaine with CHM Mardan. E-mail: kkshoaib@gmail.com, Ph: 0333-8533550 adrenaline 1: 100000) was done for fifteen minutes, in Ophthalmology Update Vol. 13. No. 2, April-June 2015 Dacryocystorhinostomy - is Endonasal Endoscopic Approach A Viable Option all the cases. In the initial ten cases, fiber optic light pipe Table-1: Per and post operative problems / complications
(20/23 G) was passed through the canaliculi into the Problems / complications
sac and at the site of transilluminated light, mucosal Bleeding in the nose obscuring view incision was made. As the bone was absent in the five through endoscope endo cases, a probe was passed from canaliculi to nose Difficulty in localization of sac area inside to identify the area. In the initial ten procedures, only nasal packing mentioned above was done. In the next Mild bleeding on first post operative day ten operations, after packing, injection of the same so- Nasal mucosal adhesions lution (2 cc of 2% xylocaine with adrenaline1:100000 Persistent watering after operations mixed with 0.5 cc of adrenaline 1: 1000) was given at the sac area and middle turbinate). Packing was done DCR is more frequently required in females. This again for ten minutes. In the next fifteen procedures, series had around 90% females and included initial after packing, cautery was done to achieve haemosta- endo DCR cases of the surgeons. It was thought that sis. Intermittent packing of ribbon gauze soaked in 2 % males are less concerned of cosmetic appearance of the xylocaine with adrenaline 100000 was required for brief scar and moreover it would be difficult to break the periods especially when bone was removed with the hard bones in them, so a few males were dealt with ex- punch and sac wall was incised. In all the cases, silicon ternal approach. All of the cases reported for DCR tube tube (Eagle, USA) was passed and ribbon gauze soaked removal six months after the operation except the two in one ml of mitomycin C (0.5 mg/ml) was placed at the who had not completed the six month stenting period. osteotomy site for ten minutes. DCR tube was removed After tube removal, only those patients visited who had after six months in all the cases except in two who have persistent problem.
not yet completed six month post operative stenting. Fiber optic light pipe was required in each case in Data was analyzed using SPSS version 15. Descriptive the initial ten cases and was used occasionally in rest statistics were used to describe the results. of the cases to confirm the sac location. A probe was passed instead of the light pipe in endo cases through the already made osteotomy. Even slight bleed in the nose results in blurring of the view through the en- doscope. Only nasal packing for fifteen minutes with 10cc of 2% xylocaine with adrenaline mixed with 0.5 cc of adrenaline 1: 10000 in the initial ten cases could not control the bleeding effectively. Injection of the Fig-2: Endo DCR instruments
same solution (2 cc of 2% xylocaine with adrenaline mixed with 0.5 cc of adrenaline 1: 10000) in the next Under general anesthesia (GA), a total of 35 endo ten cases though improved haemostasis but resulted in DCR were done in 34 patients. 3 (9%) were males and increased heart rate/blood pressure as the absorption 31(91%) were females. Age ranged from three years to from nasal mucosa was very rapid. In the rest of the sixty three years (mean 42 + 15). Follow up ranged from cases, cautery was found very useful. Surgery can be 6 to 10 months (6.5 + 2.5). During the operation prob- done with the endoscope only while attaching camera lems encountered were moderate bleeding obscuring and monitor provide the surgeon and assistant, a mag- view during six (17%) and difficulty in localization of nified view. Ronguers/punch of smaller diameter (Fig sac area in five (14%) procedures (Table 1). Post opera- 2) are easier to manipulate in the narrow nasal cavity. tive complications included mild bleeding on first post Granulation formation occluding rhinostomy site leads operative day after three (9%), nasal mucosal adhesions to failure of the procedure and recurrence of epiphora. after one (3%) and persistent watering after six (17%) To prevent it, different dosages of Mitomycin C have procedures requiring re-operation with endonasal en- been used eg. 0.5 mg/ml for 10 minutes,1 0.5 mg/ml for doscopy. Repacking controlled post op bleeding nose. 5 min,2 0.2 mg/mL for 2 min,3 0.05% nasal pack for 48 Persistent watering after five operations (16%) required hours,4 0.03% with silicone intubation5 and 0.2 mg/ml re-operation with endonasal endoscopy. Success rate for 30 minutes.6 In the present study 0.5 mg /ml for 10 after the first operation was 83% and after the second min did not cause any problem. Initial half of the cases operation was 94%, two cases did not improve, one was in this series were done by combined efforts of eye and dealt with external DCR and the other was operated ENT surgeons while later half of the cases were done third time by endo DCR.
by the eye specialist independently proving that with Ophthalmology Update Vol. 13. No. 2, April-June 2015 Dacryocystorhinostomy - is Endonasal Endoscopic Approach A Viable Option learning either of the two can do the procedure.
tive mitomycin C application in dacryocystorhinostomy. Br J Endo DCR has been done for dacryocystocoele in Ophthalmol. 2000 August; 84(8): 903–906.
a 4 month old infant7 and in adults8,9 It has been found 7. Mladina R., Stiglmayer N., Dawidowsky K., Jukic T., Jurlina M., Trupkovic-Fotivec B. Endonasal endoscopic dacryocyst- to be safe and effective procedures for the management orhinostomy for dacryocystocoele in a 4 month old infant. Br J of persistent epiphora in children10 and for adults.11 The Ophthalmol. 2001 January; 85(1): 110.
common insertion of the upper and lower canaliculus of the lacrimal sac has been repaired with endoscopic endoscopic dacryocystorhinostomy for a primary dacryocyst- 2009;5(3):179-82.
DCR followed by silicone stenting.12 Formation of mu- cosal flaps at the end of the operations has been claimed gical treatment of familial dacryocystocele and lacrimal puncta to improve success rate13, 14 and has been termed pow- 2009 Jan-Feb;25(1):52-3.
ered endonasal DCR by some while many used the 10. Marr J E, Drake-Lee A, Willshaw H E. Management of child- hood epiphora. Br J Ophthalmol. 2005 September; 89(9): 1123– term mechanical endonasal dacryocystorhinostomy (MENDCR)15 when there is large rhinostomy and mu- 11. Shiraz Aslam, Abdul Hamid Awan, Mohammad Tayyab. En- cosal flaps. Success rates of MENDCR 92%14 and 93.5%16 doscopic Dacrocystorhinostomy: A Pakistani Experience. Pak J were found to compare favorably with that of standard Ophthalmol 2010; 26 (1):2-6 12. Khan H A, Bayat A, De Carpentier JP. Endoscopic Dacrocyst- external DCR 95.8%.17 In a few studies, success was in- orhinostomy in Lacrimal Canalicular Trauma. Ann R Coll Surg ferior (86% endo - 94% ext)17 with endo DCR18 while in Engl. 2007 January; 89(1): 43.
other studies, success rates after endo DCR have been found to be equal to that of external DCR.19 Many think Anastomosis of nasal mucosal and lacrimal sac flaps in endo- that best endo DCR results are achieved by stenting or removal of the medial wall of the lacrimal sac.20 while a 14. Endoscopic transnasal dacryocystorhi- few recommend no intubation because of similar sur- nostomy with nasal mucosal and posterior lacrimal sac flap. J gical success rates, and granulation formation, patient Laryngol Otol. 2009 Mar;123(3):320-6.
15. Mechanical endona- discomfort, and increased cost with intubation.21 Nasal sal dacryocystorhinostomy--a reproducible technique. endoscopy has been recommended before and after ex- 2009 Sep;47(3):310-5.
ternal DCR2 and to treat a failed external DCR.23 16. Mechanical endonasal dacry- ocystorhinostomy versus external dacryocystorhinostomy. 2004 Jan;20(1):50-6.
Problems/complications encountered during 17. , . A Endo DCR can be managed as the procedure has good comparison of outcomes between nonlaser endoscopic endo- success rate.
nasal and external dacryocystorhinostomy: single-center expe- rience and a review of British trends. Am J Otolaryngol. 2010 . Nonlaser Endoscopic Endonasal Dacry- ocystorhinostomy with Adjunctive Mitomycin C in Nasolacri- 18. Zílelíog˘lu G, Tekeli O, Ug˘urbas SH, Akiner M, Aktürk T, An- mal Duct Obstruction in Adults. Ophthalmology adolu Y. Results of endoscopic endonasal non-laser Dacryocys- torhinostomy. Documenta Ophthalmologica 105: 57–62, 2002 19. , . A systematic review of out- endonasal dacryocystorhinostomy with adjunctive mito- mycin C in children. Ophthal Plast Reconstr Surg. 2008 Sep- 20. , . Experience with endoscopic dacryocys- torhinostomy using four methods.
tion with intraoperative mitomycin C for nasolacrimal duct ob- 2010 Mar;142(3):389-93.
struction in adults: a prospective, randomized, double-masked 21. Unlu HH, MD, Gunhan K, Baser EF, Songu M. Long-term re- study. Ophthal Plast Reconstr Surg. 2007 Nov-Dec;23(6):455-8 sults in endoscopic dacryocystorhinostomy: Is intubation re- , . Topical mitomycin ally required?Otolaryngology–Head and Neck Surgery (2009) C as a postoperative adjunct to endonasal dacryocystorhinos- tomy in patients with anatomical endonasal variants. Orbit. 22. , assessment of 2009;28(5):297-302. failure after external dacryocystorhinostomy. 2010 , dacryocystorhi- nostomy with adjunctive mitomycin C for canalicular obstruc- tion. Orbit. 2007 Jun;26(2):97-100 doscopic revision of external dacryocystorhinostomy failure. Liao S, Kao S, Tseng J, Chen M, Hou P. Results of intraopera- Ophthalmology Update Vol. 13. No. 2, April-June 2015 Ocular and systemic Complications of
Intravitreal Bevacizumab (Avastin) therapy
(12 months audit report)
Akhunzada M. Aftab Akhunzada Muhammad Aftab FCPS1, Awais Rauf MBBS2, Farooq Khan MBBS3 Syed Bilal Hassan Zaidi MBBS4, Prof. Mustafa Iqbal FRCS, MRCOphth5 Syeda Ghazala Shahnawaz MBBS, D.O6 Introduction: Since the introduction of Anti-VEGF therapy in 2005, it has been extensively used in treating ophthalmic
conditions like proliferative diabetic retinopathy, age related macular degeneration and macular edema. However intravitreal route of administration predisposes to ophthalmic complications along with few systemic adverse events too.
Materials and Methods: A retrospective analysis of the records of all patients admitted for intravitreal bevacizumab therapy
was performed during 1st January 2012 to 31st December 2012. All patients under went complete ophthalmic and systemic evaluation especially to evaluate the cardiovascular risk factors. Multiple doses of 2.5mg/ 0.1ml of bevacizumab were given from a single vial in multiple settings in a sterile environment. Ocular and systemic complications were analyzed on 1stpost operative day, 7th day and after 4 weeks.
Results: Ocular complications included sub conjunctival hemorrhage (2.19%), crystalline lens trauma (0.69%), transient
rise of IOP (0.3%), endophthalmitis (0.11%), mild uveitis (0.2%), conjunctival injection with punctate erosions (0.11%) and regurgitation of drug (0.4%). No systemic side effects of therapy were seen during the study period. Conclusion: Services provided at our institute meet the international standards and all the adverse effects and (or) complications are within inter- national standards despite use of single vial for multiple doses and multiple settings.
Key words: Bevacizumab, Intravitreal, Neovascularization, Proliferative Diabetic Retinopathy.
Genetech, San Francisco USA is available in preserva- Vascular Endothelial Growth Factors (VEGF) tive-free 100 mg/4 ml vials, and is intended for use at plays an important role in many ocular pathologies, relatively high concentrations on a single colon cancer both of the anterior and the posterior segment, lead- patient. In this era of tremendous emphasis on health ing mainly to complications like neo-vascularization care cost containment in both developed and develop- and macular edema. Since the introduction of anti- vas- ing countries, it is a common practice among hospitals, cular endothelial growth factor therapy in 2005, it has clinics, and compounding pharmacies to divide the gained wide spread popularity among ophthalmolo- large volume of bevacizumab into smaller units that are gists worldwide.1-6 Although not FDA approved, ‘off suitable for single-use intravitreal doses for individual label' use of Bevacizumab has been in practice since June 2005.7 It has been used with promising results in MATERIALS AND METHODS
conditions like Age related macular degeneration, pro- Avastin® service is being provided in Department liferative diabetic retinopathy, neovascular glaucoma, of Ophthalmology, Khyber Teaching Hospital, Pesha- clinically significant diabetic macular edema and mac- war since August 2011. The duration of this report is ular edema due to vascular occlusions.1,3-6,8-10 from 1st January 2012 to 31st December 2012. A retro- Commercially available bevacizumab (Avastin®; spective analysis of all the Avastin patients admitted in the department during the period was done as part Registrar Eye A Unit Department of Ophthalmology, Khyber Teaching Hospital, Peshawar, 2,3,4Traniee Medical Officers, A Unit Department of the annual audit of the service. After elaborating of Ophthalmology, Khyber Teaching Hospital, Peshawar, 5Prof. & detailed history of decreased vision, all the patients Head of Ophthalmology Department, Khyber Teaching Hospital, underwent complete ophthalmological examination Peshawar, 6Registrar, Ophthalmology Department, Khyber Teaching including visual acuity using the Snellen's visual acu- ity charts, best corrected visual acuity, intraocular pres- Correspondence: Dr. Akhunzada Muhammad Aftab c/o Prof. Dr. sure (IOP) measurement using the Goldman appla- Muhammad Ibrar, Department of Botany, University of Peshawar, Peshawar. Cell: 03339106060, E-Mail: nation Tonometer, pupils, slit- lamp examination for anterior and posterior segment evaluation and dilated Received: January 2015 Accepted: February 2015 fundus examination using the 90D lens (Volk, USA). Financial disclosure: There has been no financial interest involved in All intravitreal Avastin were advised by consultant this study ophthalmologists. All the patients were admitted and Ophthalmology Update Vol. 13. No. 2, April-June 2015 Ocular and systemic Complications of Intravitreal Bevacizumab (Avastin) therapy underwent a complete systemic review especially to lowed by crystalline lens trauma with needle (0.69%), exclude any cardiovascular risk factors and blood pres- which led to traumatic cataract. Post operative endoph- sure monitoring. Written informed consent was taken thalmitis was present in only one (0.11%) patient. Other from all the patients.
complications observed included transient rise in IOP, Intravitreal 2.5mg/ 0.1ml Bevacizumab (Avastin®) regurgitation of drug and mild uveitis. None of our pa- was injected in sterile environment of operation theater tients experienced any systemic side effects during the under strict aseptic technique using topical anesthesia. study duration. Figure III explains breakdown of the Multiple drug doses were drawn from the same vial and each vial served the purpose in multiple settings. In between procedures, the vial used to be stored in a TABLES & FIGURES
sterile box in a refrigerator (80 C). Standard procedure for injecting Intravitreal Avastin was followed. Topi- cal proparacaine 0.5% drops were used for anesthesia followed by instillation of 5% povidone Iodine in the conjuctival sac. Periocular scrubbing and sterile drap- ing was performed. Using a sterile 27 gauge needle, 0.1 ml of Avastin was injected into the vitreous cavity 3.5- 4 mm posterior to the limbus. Site of injection was pressed for 20 seconds to avoid reflux. Central retinal artery patency was confirmed using binocular indi- rect Ophthalmoscopy. All the patients received topical Figure-I: Distribution of different Age groups in our study
Ofloxacin drops 6 hourly post injection for one week.
Patients were followed up on first post Op day, 7th day and after 4 weeks. Patients underwent ophthalmic evaluation including visual acuity, intra ocular pres- sure measurement, anterior chamber evaluation espe- cially for signs of inflammation and (or) endophthalmi- tis, posterior chamber evaluation especially to exclude any cells, vitreous hemorrhage and dilated fundus examination using 90D lens. They were also asked to report any systemic side effects of the therapy. Patients were also reevaluated after 4 weeks for a repeat injec- tion to be given. Total number of patients receiving Avastin dur- Figure II: Indications for Intravitreal Avastin therapy. PDR (Pro-
ing the specified time period was 867. Demographic liferative Diabetic Retinopathy), CSMO (Clinically Significant
Macular Oedema), NPDR(Non Proliferative Diabetic Retinopathy),
analysis revealed 59% males (n= 512) and 41% (n= 355) CRVO(Central Retinal Vein Occlusion), BRVO(Branch Retinal vein
females. The most common age group in our study Occlusion), NVG(Neovascular Glaucoma), CSR(Central Serous
was 56-65 years (38%) followed by 46-55 years group Retinopathy), AMD(Age Related Macular Degeneration
(36%). Complete breakdown of all age groups in our study is given in figure I. The most common indication for intravitreal Avastin injection was proliferative dia- PDR with Macular Edema betic retinopathy (PDR) with macular edema (42%), fol- lowed by clinically significant macular edema (CSMO) with non proliferative diabetic retinopathy (NPDR) (29%). Indication of macular edema secondary to ve- Vitreous Hemorrhage nous occlusion was present in 10% patients. Complete breakdown of the different indications for intravitreal Table I: Indication (s) of Intravitreal Avastin Therapy. PDR
Avastin of this study period is given in figure II and (Proliferative Diabetic Retinopathy), CSMO(Clinically Significant
Macular edema), NPDR(Non Proliferative Diabetic Retinopathy),
Regarding the ocular complications, the most CRVO(Central Retinal Vein Occlusion), BRVO(Branch Retinal vein
Occlusion), NVG (Neovascular Glaucoma), CSR(Central Serous
common was sub conjunctival hemorrhage (2.19%), fol- Retinopathy), AMD(Age Related Macular Degeneration)
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Ocular and systemic Complications of Intravitreal Bevacizumab (Avastin) therapy junctival chemosis and iatrogenic vitreous hemorrhage (0.7%). Among the reported systemic complications were acute rise of blood pressure (2.7%) and mild irrita- tion and allergic reaction on skin (0.7%) [16].In our study there was one case of endophthalmitis, while rates of other complications were less. None of our study pa- tients has conjuctival chemosis or iatrogenic vitreous hemorrhage. None of our patients had systemic side effects of therapy.
A study conducted by Shima C et al, published in 2008, reported ocular and systemic side effects of intra- vitreal bevacizumab therapy in 707 patients. Results of their study included corneal abrasion 2 patients (0.28%), Conjunctival chemosis 2 patients (0.28%), Crystalline Figure-3: Ocular & Systemic complications during the study
lens injury1 patient (0.14%), ocular inflammation 2 pa- period. PEE (Punctate Epithelial Erosions of cornea)
tients (0.28%), retinal pigment epithelial (RPE) tear1 patient (0.14%) and acute vision loss1 patient(0.14%). Anti VEGF injections have become a revolutionary Systemic complications included cerebral infarction 1 treatment modality in the last decade. Its use in oph- patient(0.14%), elevation of systolic blood pressure 2 thalmologic pathologies has yielded promising results. patients (0.28%), facial skin redness 1 patient (0.14%), "of label" use of Bevacizumab (Avastin)is gaining wide itchy diffuse rash 1 patient(0.14%)and menstrual irreg- popularity not only because of the promising results ularities 3 patients (0.42%).17 While in our study com- but also its easy availability and a relatively cheap cost. plications like RPE tear, sudden loss of vision and sys- As already mentioned most centers, hospitals and clin- temic side effects were not seen. A retrospective study ics divide the vial into multiple small doses, reducing conducted by Johnson D et al, at the Department of the cost per injection further.
Ophthalmology, Queens Hospital Kingston, Ontario,9 The dose of Bevacizumab used in ophthalmology (1.30%) cases of acute intraocular inflammation were is small as compared to the intravenous dose used in seen out of 693 injections given.18 carcinoma colon, still, various ocular and systemic com- plications have been reported worldwide.7, 10- 15 In our Intravitreal Bevacizumab therapy has fewer side study, out of a total of 867 patients, only 36 patients de- effects as compared to systemic administration. The veloped ocular side effects of the therapy while no pa- ocular side effects of our study are well within range of tient experienced any systemic side effects in the study international studies. In order to avoid systemic com- duration. Out of these 36 patients, 29 had per operative plications, admission of all the patients and strict car- complications like sub conjunctival hemorrhage, crys- diovascular evaluation is mandatory. Using the same talline lens trauma and regurgitation of drug. The most vial for multiple doses and being used in multiple set- common age group in our study was 56- 65 years (38%), tings do not seem to increase the risk of ocular and (or) and the most common indication for therapy was pro- systemic complications. Multiple dosing from a single liferative diabetic retinopathy with macular edema vial can reduce the total patient cost tremendously. The (42%). Ocular complications in our study included sub- operative complications can be avoided by adopting conjuctival hemorrhage (2.1%), crystalline lens trauma proper procedure and employing trained ophthalmolo- (0.6%) which led to traumatic cataract, transient rise of gists for the procedure.
intra ocular pressure (0.3%), mild uveitis (0.2%), en- dophthalmitis (0.1%), conjunctival injection with punc- Avery RL, Pieramici DJ, Rabena MD, et al. Intravitreal beva- cizumab (Avastin)for neovascular age-related macular degen- tate epithelial erosions (0.1%) and regurgitation of drug (0.4%). No patient (0%) had any systemic side effects in Manzano RP, Peyman GA, Khan P, Kivilcim M. Testing intravit- the study duration.
real toxicity ofbevacizumab (Avastin). Retina 2006;26(3):257–61.
Spaide RF, Fisher YL. Intravitreal bevacizumab (Avastin) treat- In another study conducted by Fasih U et al, out of ment of proliferative diabetic retinopathy complicated by vitre- 150 patients receiving intravitreal bevacizumab, ocular ous hemorrhage. Retina2006;26:275–8.
complications included sub conjunctival hemorrhage 4. Iturralde D, Spaide RF, Meyerle CB, Klancnik JM, Yannuzzi LA, Fisher YL, Sorenson J, Slakter JS, Freund KB, Cooney M, (23%), regurgitation of drug (5.3%), transient rise of Fine HF. Intravitreal bevacizumab (Avastin) treatment of mac- IOP (4.7%), mild uveitis (2.7%), lens injury (2%), con- ular edema in central retinal vein occlusion: a short-term study. Ophthalmology Update Vol. 13. No. 2, April-June 2015 Ocular and systemic Complications of Intravitreal Bevacizumab (Avastin) therapy A, Vergados I. Safety of repeat intravitreal injections of beva- Avery RL. Regression of retinal and iris neovascularization cizumab versus ranibizumab: our experience after 2,000 injec- after Intravitreal bevacizumab (Avastin) treatment. Retina tions. Retina. 2009; 29(3):313-18.
14. Fintak DR, Shah GK, Blinder KJ, et al. Incidence of endoph- Mason JO III, Albert MA Jr, Vail R. Intravitreal bevacizumab thalmitis related to intravitreal injection of bevacizumab and ranibizumab. Retina. 2008; 28(10):1395– 99. Refractoryp seudophakic cystoid macular edema. Retina 15. Diago T, McCannel CA, Bakri SJ, Pulido JS, Edwards AO, Pach JM. Infectious endophthalmitis after intravitreal injection of an- FungA E, RosenfeldP J, ReichelE. The International Intravitreal tiangiogenic agents. Retina. 2009; 29(5):601– 05.
Bevacizumab SafetySurvey: using the internet to assess drug 16. Wu L, Martinez- Castellanos MA, Quiroz-Mercado H, Areva- safety worldwide. Br J Ophthalmol 2006;90:1344-49.
lo JF, Berrocal MH, Farah ME, Maia M, Roca JA, Rodriguez Kahook MY, Schuman JS, Noecker RJ. Intravitreal bevacizum- FJ; Pan American Collaborative Retina Group (PACORES). ab in a patient withneovascular glaucoma. Ophthalmic Surg Twelve-month safety of intravitreal injections of bevacizumab Lasers Imaging 2006;37:144-6.
(Avastin): results of the Pan-American Collaborative Retina 10. Spaide RF, Laud K, Fine HF,Klancnik JM Jr, Meyerle CB, Yan- Study Group (PACORES). Graefes Arch Clin Exp Ophthalmol. nuzzi LA, Sorenson J, Slakter J, Fisher YL, Cooney MJ. Intra- vitreal bevacizumab treatment ofchoroidal neovasculariza- 17. Fasih U, Shaikh N, Rahman A, Sultan S, Fahimi MS, Shaikh A. tion secondary to age-related macular Degeneration. Retina Ocular and systemic complications of intravitreal injection bevacizumab( avastin ) in one year follow up(a study of 150 11. Rich RM, Rosenfeld PJ, Puliafito CA,Dubovy SR, Davis JL, cases). J Pak Med Assoc. 2013;63(6):707-10.
Flynn HW Jr, Gonzalez S, Feuer WJ, Lin RC, Lalwani GA, 18. Shima C, Sakaguchi H, Gomi F, Kamei M, Ikuno Y, Osh, Nguyen JK, Kumar G. Short-term safety and efficacy of in- Sawa M, Tsujikawa M, Kusaka S, Tano Y. Complications in travitreal bevacizumab (avastin) for neovascular age-related patients after intravitreal injection ofbevacizumab. Acta Oph- macular degeneration. Retina 2006;26(5):495–511.
thalmol. 2008; 86:372–76.
12. Danny S N, Alvin KK, Clement WC, Walton WT. Intravitreal 19. Johnson D, Hollands H, Hollands S, Sharma S. Incidence and bevacizumab: safety of multiple doses from a single vial for characteristics of acute intraocular inflammation after intravit- consecutive patients. Hong Kong Med J 2012;18:488-95.
real injection of bevacizumab: A retrospective cohort study. 13. Ladas ID, Karagiannis DA, Rouvas AA, Kotsolis AI, Liotsou Can J Ophthalmol. 2010;45(3):239-42.
Metastatic ocular melanoma
A 35-year-old male patient presented to our OPD with complaint of sudden painless decreased vision for 4-5 months in left eye. Visual acuity was 6/6 OD and CF OS. There was a large mass supero-temporally just posterior to and indenting the crystalline lens. Fundus examination revealed large elevated amelanotic lesion superior to superior arcade and exudative retinal detachment inferiorly. Enucleation was done and the specimen was sent for Curtesy: Dr Hussain Ahmad Khaqan Department of Ophthalmology, Lahore General Hospital/PGMI, Lahore.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Incidence of Intraocular Foreign Body
in Penetrating Trauma presented to a Tertiary
Care Hospital of Khyber Pakhtun Khwa
and its Visual Outcome
Mohammad Idris FCPS1, Zubairullah Khan FCPS2, Hasan Yaqoob FRCS3 Asim Ali Shah FCPS4 Objective: to determine the Frequency of Intraocular foreign body in penetrating injury presented to a tertiary care centre
of Khyber Pakhtunkhwa for management and its visual outcome.
Study design: prospective, interventional case series
Material and Methods: The study was carried out at Department of Ophthalmology, Govt Lady Reading Hospital, Pesha-
war from July 2010 to Jan 2013. We received 100 cases from outdoor department for management. Patients were examined after detailed history and important findings noted. Data was collected on special proforma and was analyzed with the help of SPSS Version16.
Results: The study comprised of 100 cases. In 37 (37%) patients with penetrating ocular injury, IOFB was found. 73 (73%)
patients were male and majority was young patients. Students and children were in majority, 38 (38%) patients were stu- dents, 35 (35%) patients were labors, and 15 (15%) patients were related to sports and defense. Commonest reason of penetrating injury was toys, stone and metal and glass pieces. Main reason for poor visual acuity was late presentation and BBI (bomb blast injuries).
Conclusion: Occupation like labor, sports, defense and children are persons who are constantly prone to penetrating
trauma and IOFB. In case of school children, teachers can play a vital role in prevention and timely referral to a tertiary care centre. Commonly male and young people are risk group people and should be advised to wear protective goggles during outdoor work. Visual progression was poor in majority of the eyes; delayed presentation and BBI were the top reasons. Most serious cause of penetrating trauma was BBI.
Key words: penetrating trauma, intraocular foreign body, ocular trauma, visual outcome.
and young patients working on fields which are ex- Penetrating ocular trauma is a serious type of in- posed because of their occupations. In this regard, lack jury to the globe. Intraocular foreign bodies (IOFBs) of awareness regarding protective goggles and early are the major cause of penetrating ocular trauma and referral to eye specialist for urgent management is lack- the most serious problem is the resulting impairment ing.4, 5 Most ocular injuries in this rural population oc- of visual function. Special attention should be paid on curred at the workplace, suggesting the need to explore primary and secondary complications, which include workplace strategies to minimize ocular trauma as a mechanical lesions of the ocular tissues, metallosis priority. Eye care programs targeting high-risk ocular and endophthalmitis.1 Ocular trauma associated with trauma groups may need to consider ocular trauma as intraocular foreign bodies (IOFBs) is one of the ma- a priority in eye health awareness strategies in order to jor causes of visual impairment in young individuals. reduce its incidence.6 Various reports indicate that 18-41% of all open globe injuries involve at least one IOFB.2 The study was carried out at Department of Oph- In a study, the intraocular foreign body in open thalmology, Govt Lady Reading Hospital, Peshawar globe injury was found in 45 eyes (38%). In our study from July 2010 to Jan 2013. We received 100 cases from it was seen in 37% cases.3 Most of the victims are male outdoor department and were admitted for manage- 1Medical Officer, Ophthalmology UNIT, PGMI, LRH Peshawar, KPK, ment. This was a prospective, interventional case series 2Senior Medical Officer, Ophthalmology UNIT, PGMI, LRH Peshawar, of consecutive patients with IOFBs. Patients were exam- KPK, 3Consultant, Ophthalmology UNIT, North West General, Hos- pital, Peshawar, KPK, 4Medical Officer, Ophthalmology UNIT, PGMI, ined after detailed history and important finding were LRH Peshawar, KPK. noted. The following variables were recorded for the purpose of the study: age, gender, cause of trauma, oc- Correspondence: Dr. Mohammad Idris, Medical Officer, Ophthalmol- ogy UNIT, PGMI, Lady Reading Hospital, Peshawar. cupation, complications, presenting best-corrected vis- Cell No.: +92-333-9182595, Email: idrisdaud80@gmail.com ual acuity (BCVA), slit lamp and fundus examination, Postal Address: Ophthalmology UNIT, PGMI, LRH Peshawar, KPK ultrasound examination when ophthalmoscopy was Received: August 2014 Accepted: November 2014 not possible, foreign body localization based on orbital Ophthalmology Update Vol. 13. No. 2, April-June 2015 Incidence of Intraocular Foreign Body in Penetrating Trauma presented to a Tertiary Care Hospital of Khyber Pakhtun Khwa and its Visual Outcome CT scan, size, site, and type of the foreign body, conse- quences of retained IOFB including complications, time Table1: Clinical characteristics of subjects
interval since injury, details were recorded. All patients with penetrating trauma (N=100)
underwent surgical removal of the IOFB. Final visual number percentage acuity at 6 month follow up visit was noted. Data was collected on special proforma and was analyzed with the help of SPSS Version16; on probability consecutive sapling technique was used.
Inclusion criteria: patients with history of intraocular
foreign body.
Exclusion criteria: patients with history of ocular dis-
Causes of intraocular injury ease especially diabetic retinopathy, high myopia, past Hammering a chisel Bomb blast injury ocular surgery and bleeding disorders.
Sports or accidental We analyzed 100 cases of patients who suffered occupation of patients penetrating ocular trauma. Various aspects of subjects Sports and defense with penetrating trauma are presented in Table1. Re-
garding gender distribution, 73 (73%) patients were Others / accidental male and only 27(27%) Patients were female. We di- Final visual outcome vided age into 03 groups. 38 (38%) patients were young Perception of light to no perception of light No Counting finger or better with age less than 20 years. 53 (53%) patients have age ranging from 21 to 40 years and only 09 (09%) patients Table-2: Frequency of intraocular foreign
have age 40 years or old. So majority were young pa- body in penetrating trauma
tients. Different causes of the penetrating trauma were Frequency
determined and presented. Hammering a chisel was the main cause and it was seen in 33 (33%) cases. bomb blast injury was seen in 17 (17%) patients and sports or accidents were seen in 44 (44%), while other causes reported unknown by the patients were 06 (06%) cases.
Different occupation of patients were divided and presented. Students and children were in majority, 38 (38%) patients were student, 35 (35%) patients were labors, and 15 (15%) patients were related to sports and defense activities. Occupations other than above Fig-1: Different Intra Ocular Foreign Bodies recovered
were found in 12(12%) patients. Finally visual outcome from the globe: (photo by DR MOHAMMAD IDRIS, eye unit,
was shown in table 1., generally the final visual acuity Lady Reading Hospital, Peshawar)
was poor in majority of the patients. We divided the patient's visual acuity into Perception of light (PL) to In this study we evaluated cases with penetrat- no perception of light and counting finger or better. ing intraocular injury that underwent repair and with 37 patients were having visual acuity of perception of or without foreign body removal. The visual outcomes light to no perception of light. 63 patients have count- and complications of surgical management were deter- ing finger or better vision. PL was mostly in BBI and mined. The final visual acuity, and important observa- cases which were presented late. So majority had poor tions reported in the literature were compared to the prognosis even after treatment, at six months follow present study.
up period. Main reason for poor visual acuity was late With successive wars in the twentieth centu- presentation and BBI.
ry, there has been a relative increase in injuries to Table 2 shows frequency of IOFB in 100 cases pre- the eye compared to injuries of other parts of the body. sented to the emergency department for management. The main causes of eye injury have changed with ad- out of 100 cases, 37 (37%) patients have IOFB detect- vances in techniques and weaponry of warfare, with ed either clinically or using imaging techniques like, blast fragmentation injuries accounting for 50-80% of X-rays, CT-scan and ultrasound B-scan. In 63 (63%) cases.7 In our study, Mostly victims are those working patients with penetrating ocular injury, no IOFB was in the field and exposed to environment. According Ophthalmology Update Vol. 13. No. 2, April-June 2015 Incidence of Intraocular Foreign Body in Penetrating Trauma presented to a Tertiary Care Hospital of Khyber Pakhtun Khwa and its Visual Outcome to different studies7, 8, 9 despite early referral, BBI were Visual progression was poor in majority of the eyes due having worse prognosis and despite proper manage- to delayed presentation and BBI were the top reasons. ment and early intervention, results and final visual Most serious cause of penetrating trauma was BBI. FBs outcome were poor and disappointing. It was mainly like wood and stone were strongly associated with en- because of multiple and complex type of injuries and dophthalmitis which needs local and systemic antibi- severe ocular damage.
otics should be advocated in any trauma particularly The most common causes of open globe injury contaminated ones.
are domestic accidents and occupational injuries. Sig- Recommendations: Awareness regarding early re-
nificant prognostic factors for final visual outcome in ferred to the tertiary care hospital, when facilities of vit- patients with open globe injury are initial visual acuity, rectomy is available for IOFB removal with out delay. posterior extent and length of wound, presence of hy- Any FB can enter the eye and cause damage so the need phaema and presence of vitreous prolapse. Awareness of imaging is stressed in every suspected case.Majority of the factors predicting a poor visual outcome may be of patients with IOFB were male, laborer and workers, helpful during counseling of patients with open globe so the incidence can easily be reduced with adopting simple measures like safety goggles use during work Several studies confirm that trauma of any type because in most of the cases prognosis is poor and pre- is common in male11 in our study males were in ma- vention is better.
jority also. Similarly young to middle age people are the common group of people exposed to both acciden- characteristics of penetrating ocular injuries with intraocular tal as well as occupational trauma.4, 5 Most of our pa- foreign body. Part I. Pathogenesis and clinical tients were less than 40 years age. Penetrating ocular 2010; 112:70-6.
injuries with retained posterior segment foreign bod- Kuhn F, Mester V, Morris R. Intraocular foreign bodies. In: Kuhn F, Pieramici D, editors. Ocular Trauma: Principles and ies are challenging cases requiring urgent attention by Practice. USA: Thieme Medical Publishers; 2002.
vitreoretinal surgeons. Posteriorly located injuries can result in serious immediate and delayed vitreoretinal 2011 ;20:377-80.
sequelae, such as retinal detachment and endophthal- ,. Visual outcome after open globe injury and its mitis. et al, reported the rates of retinal de- predictive factors in Korea. 2010 ;69:E66-72.
tachment and endophthalmitis were 41% (17/41) and Prognostic factors influencing final visual acuity in open globe 17% (7/41) respectively.12 Several studies have shown 2011 ;71:1794-800.
that the visual prognosis is poor. In a study, Visual acu- ity on admission between 6/60 to PL comprises highest ,. Ocular trauma in a rural population of south- ern India: the Andhra Pradesh Eye Disease number (64%) and also on discharge between 6/60 to 2006 ;113:1159-64.
PL comprises highest number of cases (50%) of IOFB.3 ,,Eye injuries in twentieth century In eye injury patients, the nature of the foreign body determines the clinical behavior; inert objects such as steel and glass may not cause significant inflamma- gists, suicide bombings and getting it right in the emergency tion to warrant their removal. Removal of organic for- eign bodies, however, is mandatory since these objects . Explosions and blast injuries. usually lead to secondary infection, like endophthalmi- 2001; 37:664-78.
laysia - A 10-year review. 2014 18;7:486-490. Occupation like labor, sports, defense and chil- dren are persons who are constantly prone to pen- tern of ocular trauma in the western region of Nepal. 2012 ;4:5-9.
etrating trauma and IOFB. In case of school children, teachers can play a vital role in prevention and timely ment intraocular foreign bodies referral to a tertiary care centre. Commonly male and 1999 ;34:23-9.
,and management of orbital young people are risk group people and should be ad- inflammation and infections secondary to foreign bodies: a vised to wear protective goggles during outdoor work. clinical revie 1998 ; 17:247-69.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 To Determine the Efficacy of Tattoo
Ink in Changing the Color of Rabbit's Iris
Mehdi Soltanifar MBBS1, Jahanzeb Durrani, DOMS, FICO2 Aim: To determine the efficacy of tattoo ink in changing the color of rabbits iris.
Methods: The research was carried out on rabbit eyes. The dye used to change the color of the iris was the standard tattoo
ink. Five different colors of tattoo ink were used and these include red, yellow, green, blue and brown. All the eyes underwent intra-ocular pressure measurement, The anterior chamber reaction and iris atrophy was assessed. A record of iris color was kept by serial photographs. After anesthetizing the rabbit a port was made at the limbus at the 12 o'clock position preformed tattoo ink was injected in the anterior chamber. The Anterior chamber was washed after ten minutes in group (A) of rabbits and after twenty four hours in group (B) of rabbits with balanced salt solution. The wound was sealed via stromal hydration. Topical antibiotic-steroid drops were used to post operatively.
Results: Our study included 20 eyes from 10 rabbits. The right eye of each rabbit was used as a control. The IOP, AC cell
count and AC flare stayed constant in right eye over one month follow up. The left eye however had significantly decrease in IOP at 1week and 1 moth; p=0.00. The AC cell count and AC flare was significantly high in left eye as compared to the baseline; p< 0.05. All rabbits had round regular pupil responding to light at the baseline. Iris atrophy was not seen in any rabbit at the baseline and also not at 1 week or 1 month. In all rabbits of group A no color change in iris occurred. However in group B all rabbits showed change of color of iris. The color could be seen in the form of membranes of color formed in front of the iris. However, the cornea and the lens did not take up any color and did not show any staining. In group A there was some pigment in the epithelial cells but no color could be demonstrated in the stroma. In group B the color deposits can be seen in the epithelial cells, in the macrophages of the stroma and also in the extracellular matrix of the stroma.
Conclusion: Tattoo ink changed the color of iris if retained in the anterior chamber for 24 hours. It caused complications of
decreased intraocular pressure and increased anterior chamber cell count and flare. No iris atrophy occurred. The change in color of iris was patchy for most colors but for blue ink the whole iris color change occurred. than 4 mmHg before and after the procedure will be The color of the iris has important implications in the cosmetic appearance of a person's eyes. Different 2-Anterior chamber reaction: A cell count of more than
optical aids have been developed to change the color of fifteen and a flare of more than +2 will be considered the iris and hence the appearance of the eyes. These de- vices include colored contact lenses and anterior cham- 3-Iris atrophy: The pupillary size and excursion to light
ber intra ocular lenses. Both these aids have their ad- will be compared with the other eye to determine dam- vantages and associated complications. Tattoo ink can age to the iris muscles. Iris atrophy will be recorded as also be used to change the color of the iris. It has been being either present or absent.
used in humans on the skin for a long time. The tat- 4-iris colour: The color of the iris before the use of tat-
too ink is ingested by the fibroblasts and permanently too ink will be compared to its color after its use.
changes their color. The aim of this research is to use MATERIAL AND METHODS
tattoo ink to change the color of the iris in animal mod- Setting: Department of Ophthalmology Pakistan Insti-
els. The research will be carried out in rabbit eyes be- tute of Medical Sciences, Islamabad.
cause of their close anatomical resemblance to human Duration of Study: 6 months after approval of synopsis.
eyes. The eyes will then be monitored for a change in Sample: Size twenty eyes of ten rabbits with one eye of
the color of the iris as well as any possible side effects.
each animal being used as control.
Sampling Technique: Non probability (convenience)
The safety and efficacy of the ink will be judged according to the following parameters; 1-Intraoccular pressure (IOP) A difference of more 1. Healthy adult rabbits with normal eyes.
2. Age from 2 to 6 months 1,2Postgraduate Trainees for M.S, Ophthalmology PIMS, Islamabad Correspondence: Dr. Mehdi Soltanifar MBBS, Postgraduate Trainee 1. Any ocular pathology for M.S. Ophthalmology, PIMS, Islamabad. 2. Age less than 2 months and greater than 6 months Email: mehdisoltanifar@yahoo.com, Ph: 00989155410462 Data Collection Procedure: The dye that will be used
Received: October 2014 Accepted: November 2014 to change the color of the iris is standard tattoo ink. The Ophthalmology Update Vol. 13. No. 2, April-June 2015 To Determine the Efficacy of Tattoo Ink in Changing the Color of Rabbitts Iris concentration of the dye will be standardized by cen- mean of 27.6±2.37. At 1 week the IOP ranged from 18.5 trifuging one milliliter of ink to remove the fluid fol- to 25.8 with a mean of 22.4±3.63. At 1 month the IOP lowed by washing with normal saline. One milliliter decreased further and ranged from 14 to 25.8 with a of hydroxy methyl cellulose will then be added to this mean of 19.6±5.59. The decrease in mean IOP at 1 week was compared to IOP at baseline and a mean decrease of 5.15±4.09 was noted, this difference was statistically significant; p=0.003 (using paired sample t test). The decrease in mean IOP at 1 month was compared to IOP at baseline and a mean decrease of 8.02±6.57 was noted, this difference was statistically significant; p=0.004. Anterior chamber cell count in rabbits eye: At 1 week
however 6 (60%) had +1 and 4 (40%) had +2 cells in the AC. At 1 month it improved in one (10%) patient and no cell were seen. However in 5 (50%) +1 cells and in 4 (40%) +2 cells were seen. The cell count in AC was sig- nificantly higher at 1 week and at 1 month as compared to the baseline; p=0.00.
Anterior chamber flare in rabbits eye:. At 1 week how-
ever 3 (30%) had no flare, 3 (30%) had +1 flare, 2 (20%) had +3 flare and 2 (20%) had +4 flare in the AC. At 1 All the eyes will undergo intra-ocular pressure month the condition was the same as at 1 week. The measurement by Schiotz tonometer. The anterior flare in AC was significantly more at 1 week and at 1 chamber reaction and iris atrophy will be assessed by month as compared to the baseline; p=0.009.
slit lamp biomicroscopy. A record of iris color will be Pupillary reaction: Two rabbits however developed
kept by serial photographs. All these variables will be sluggish left pupil at 1 week and at 1 month. measured one day before the injection of tattoo ink then Iris atrophy: Iris atrophy was not seen in any rabbit at
two weeks after the injection finally one month after the the baseline and also not at 1 week or 1 month. Color change of iris: In all rabbits of group (A) no color
The rabbits will be anesthetized by an intramus- change in iris occurred. However in group (B) all rab- cular injection of forty percent ketamine, xylazine Hy- bits showed change of color of iris. The color could be drochloride and Atropine. After anesthesia the head seen in the form of membranes of color formed in front of the rabbit will be fixed. A port will be made at the of the iris. However, the cornea and the lens did not limbus at the 12 O' clock position. Viscoelastic will be take up any color and did not show any staining. injected in the anterior chamber for deepening it and Histopathology: In group A there was some pigment in
protecting the cornea. Finally, preformed tattoo ink will the epithelial cells but no color could be demonstrated be injected in the anterior chamber through the same in the stroma. In group B the color deposits can be seen port. The Anterior chamber will be washed after ten in the epithelial cells, in the macrophages of the stroma minutes in group (A) of rabbits and after twenty four and also in the extracellular matrix of the stroma. hours in group (B) of rabbits with balanced salt solu- tion. The wound will be sealed via stromal hydration. Topical antibiotic-steroid drops will be used to post op- Data analysis: The data will be stored and analyzed in
SPSS (10). Frequency (percentages) will be calculated for all the variables including intraocular pressure, anterior chamber reaction, irisatrophy and iris color. Chi-square test will be used as the test of significance. P value of <0.05 will be considered as significant.
Intraocular pressure: The IOP in right eye ranged
from 25.8 to 30.4 with a mean of 27.6±2.37. In the left eye the baseline IOP ranged from 25.8 to 30.4 with a Ophthalmology Update Vol. 13. No. 2, April-June 2015 To Determine the Efficacy of Tattoo Ink in Changing the Color of Rabbitts Iris Differences between different colors: The response ob-
intraocular pressure in rabbits´ eyes may be due to re- served with different colors was varied. For example duced fluid production by the ciliary body in response with blue and yellow color the change in color was ho- to the dye. However, reduced pressure does signify the mogenous however with brown, green and red color fact that the tattoo ink did not block the outflow tracts the color change was patchy and inhomogeneous. of the anterior chamber.
Tattoo inks have their own hazards even when Different optical aids have been developed to used on the skin, In our study the injection of tattoo change the color of the iris and hence the appearance of ink was associated with development of inflammation the eyes. These devices include colored contact lenses as evidenced by significant increase in cell count and and anterior chamber intra ocular lenses. Both these development of flare in the anterior chamber. How- aids have their advantages and associated complica- ever, tattoo ink was quite safe in our study since no tions. Anterior chamber intra ocular lenses have been case of iris atrophy was observed. Since the previous used to mask the original color of the iris and improve methods had their own limitations attempts at invent- the appearance of patients with iris colobomas. The ing a new method that is successful in changing the eye complications associated with these include uveitis, iris color without side effect will continue. Our study was atrophy, glaucoma, endophthalmitis, pupillary abnor- one such effort. Further studies are required in the field malities, haloes and reduced vision at night. Colored with slight changes in the tattoo chemistry and its sol- contact lenses are easy to use and are widely employed vent that can improve the results in future. to change the color of the iris for cosmetic reasons. Con- tact lens use has been associated with uveitis, epithelial Tattoo ink changed the color of iris if retained in keratopathy and allergic reactions. Tattoo ink can also the anterior chamber for 24 hours. It caused complica- be used to change the color of the iris. The immediate tions of decreased intraocular pressure and increased uptake of the ink by the fibroblasts, together with the anterior chamber cell count and flare. No iris atrophy occurred. The change in color of iris was patchy for scarcity of these cells in the endothelial layer of the cor- most colors but for blue and yellow ink are homog- nea and anterior capsule of the lens ensures that these enous and whole iris color change occurred.
structures in the anterior chamber do not change their color and react minimally to the presence of the ink. Druianova IUS, Verigo EN, A rational method of cosmetic eye We carried out a study at PIMS hospital to see the efficacy of tattoo ink in changing color of iris. The study 2. Mamalis N: Complications of foldable intraocular lenses requiring explantation or secondary intervention. J Cataract was carried out at Department of Ophthalmology, Refract Surg 2002;28: 2193-201.
PIMS Islamabad. The research was carried out on rab- Sorbara L., Jones, L. Williams-lyn D. Contact lens induced bit eyes. The response observed with different colors papillary conjunctivitis with silicone hydrogel lenses. Cont Lens Anterior Eye 2009;32:93-6 was varied. For example with blue and yellow color the change in color was homogenous however with brown permanent make-up: background and complications. MMW and red color the color change was patchy and inho- Fortschr Med 2006;148:34-6.
mogeneous. Each tattoo color has a different chemical Bron AJ, Tripathi RC, Tripathi BJ. Wolff's Anatomy of the Eye and Orbit.8th edn. Chapman & Hall Medical: London, 1997.
formula which is a secret of the company manufactur- Imesch PD, Wallow IH, Albert DM. The colour of the human eye: ing it. The differences observed in the homogeneity of a review of morphologic correlates and of some conditions that color change may be due to differences in the chemical affect iridial pigmentation. SurvOphthalmol1997;41:117–23. Wilkerson CL, Syed NA, Fisher MR, Robinson NL, Wallow nature of the different colors.
IH, Albert DM. Melanocytes and iris colour. Light microscopic From our study it is evident that the color change findings. Arch Ophthalmol 1996;114:437–42.
occurs if the dye is retained in the anterior chamber for Prota G, Hu DN, Vincensi MR, McCormick SA, Napolitano A. Characterization of melanins in human irides and cultured 24 hours. Complications included features of inflam- uveal melanocytes from eyes of different colours. Exp Eye Res mation which settled by the end of one month in some 1998;67:293–99. eyes. It caused complications of decreased intraocular Fuchs E. Normal pigmentierte und albinotische iris. Graefes pressure and increased anterior chamber cell count and 10. Dieterich CE. [The fine structure of melanocytes in the human flare. No iris atrophy occurred. The reduction in the Ophthalmology Update Vol. 13. No. 2, April-June 2015 Incidence of Hepatitis B & C among Admitted
Eye Patients in Tertiary Care Hospital of Peshawar
Bilal Bashir FCPS1, Muhammad Zubair Masud FCPS2, Muhammad Nazim FCPS3 Bilal Khan FCPS4, Mahfooz Hussain FRCS5 Purpose: To determine the frequency of sero-positive cases of Hepatitis B & C viral infection in the admitted patients un-
dergoing elective eye surgery in tertiary care hospital.
Material and Method: It was a descriptive study based on survey in which all patients above 2 years of age admitted for eye
surgery in Eye unit of Lady Reading Hospital Peshawar were screened for Hepatitis B and C infections, from 1st July 2013 to 30th June 2014. Those found positive on screening test were confirmed by Enzyme Linked Immunosorbant Assay (ELISA).
Result: Total number of patients screened was 1147. Male patients were 54.31% (623/1147) and female patients were
45.68% (524/1147). The frequency of hepatitis B and C (combined) was found to be 5.66% (65/1147); out of which 2.5% (29/1147) were HBsAg positive and 3.13%(36/1130) anti-HCV positive
Conclusion: Screening of blood borne viral infections has important role in minimizing the transmission of the virus to doc-
tors, paramedics and other patients.
of these diseases is more among patients receiving Hepatitis is described as an infection with swell- blood transfusions or injection drug users.9,10 Patients ing and inflammation of the liver that if progresses, presenting to different public and private hospitals are may lead to cirrhosis or cancer. Sometimes people con- not routinely screened for hepatitis B and C. There- tract hepatitis with limited or no symptoms but often fore there is high risk of transmission of infection from it leads to jaundice, anorexia (poor appetite) and diar- asymptomatic carrier patients. Keeping in view the rhea. Hepatitis is caused by a wide variety of causatives dreadful complications of hepatitis and its high infec- like alcohol, poison and autoimmunity but most cases tivity we cannot take the risk of operating on patients of hepatitis are reported by viruses. Pakistan has large without hepatitis screening. This study was carried out number of both diagnosed and un-diagnosed patients to discover the frequency of hepatitis B and C in our of hepatitis B and C. The prevalence among general surgical patients to get an idea about the number of the public of HBV and HCV infection in Pakistan is 10%2,3 patients we are operating on them without knowing and 4–10%4,5 respectively. Hepatitis B virus (HBV) in- that whether they are hepatitis B or C positive.
fection is endemic worldwide and is responsible for MATERIAL AND METHODS
an estimated 1-2 million deaths worldwide every year. This prospective observational study was con- About 350 million (5- 15 % of the total cases) are carriers ducted at Eye Unit, Lady Reading Hospital Peshawar of the virus, out of which around 80% reside in Asia.6 from July 2013 to June 2014. A total of 1147 patients un- According to WHO estimates, HCV prevalence is 3% of der going eye surgery, who were unaware of hepatitis world population with 170 million cases. Almost 50% infection were included in this study. After taking ethi- of all cases become chronic carriers at risk of liver cir- cal approval from the department, patients informed rhosis and liver cancer.7 consent was taken. Rapid chromatography immunoas- HBV can be transmitted through blood, semen, say for qualitative detection of hepatitis B and C was vaginal fluids and other bodily fluids of the infected the screening method. Those found positive on screen- individual.8 HCV however, can only be contracted ing test are confirmed by ELISA. A special proforma through blood to blood contact. The transmission risk is made for this study and results were analyzed by Medical Officers Lady Reading Hospital Peshawar. 2Assistant Professor Naseer Teaching Hospital Peshawar. 3Medical Officer Al Khidmat Hospital Peshawar. 5Assistant Professor Lady Reading Total number of patients screened were 1147. Male Hospital Peshawar subjects were 54.31% (623/1147) and female subjects Correspondence: Dr. Bilal Bashir, House no 103 New Defence were 45.68% (524/1147). The frequency of hepatitis B Officers Colony Shami Road Peshawar Cantt Ph: 03339115764 / and C (combined) was found to be 5.66% (65/1147); out of which 2.5% (29/1147) were HBsAg positive and Received: November 2014 Accepted. January 2015 3.13%(36/1130) anti-HCV positive. The frequency of Ophthalmology Update Vol. 13. No. 2, April-June 2015 Incidence of Hepatitis B & C among Admitted Eye Patients in Tertiary Care Hospital of Peshawar HBV was 75.8%(22/29) in males and 24.13% (7/29) in the total prevalence of Hepatitis B & C in males was females. The frequency of HCV was 66.66% (24/36) in higher than females among preoperative cataract pa- males and 33.33% (12/36) in females. No patient was tients of D I Khan.18 Surprisingly some studies have diagnosed with both Hepatitis B and C co infection.17 shown higher prevalence of Hepatitis B and C in fe- males than in males.19 A study conducted in different Eye camps of Pakistan in 2010 showed higher prev- alence of the diseases in females with 60.18% than in males with 39.81%.20 Our study has shown that there is high prevalence of Hepatitis B and C in patients admitted for elective Eye surgery. Therefore Hepatitis screening is mandato- ry in all preoperative patients. This will prevent trans- mission of infection to both medical staff and other patients. We recommend mass immunization against Hepatitis B and awareness to public through print and electronic media. Larger population based studies are needed to confirm the results.
2. Yusaf A, Mahmood A, Ishaq M, et al. Can weafford to oper- ate on patient without HBsAg screening. J Coll Phys Surg Pak. Malik IA legters LJ,Luqman M,et al.The serological markers of hepatitis A and B in healthy population in northern Pakistan. J Pak MedAssoc. 1988; 38: 69-72.
Malik IA, Khan SA, Tariq WUZ. Hepatitis C virus in prospec- tive: where do we stand, (editorial ). J Coll Phys Surg Pak. 1996; Umar M, Bushra HT, Shuaib A, et al. Spectrum of chronic liver The incidence of hepatitis B and C has achieved disease due to HCV infection. J Coll Phys Surg Pak. 1999; 9: endemic situation in many countries of the world, espe- cially in under developed countries. Pakistan also has 6. World Health Organization: Hepatitis B. (Fact sheet no. 204). Geneva,Switzerland: World Health Organization; 2000.
high prevalence of Hepatitis B and C. Most common World Health Organization: Hepatitis C. (Fact sheet no. 204). source of spread of these infections is through the use Geneva, Switzerland: World Health Organization; 2000.
of unsterilized syringes or instruments especially den- Maheshwari A, Thuluvath PJ: Management of acute hepatitis tal instruments or unchecked blood transfusion. Other C. Clinics in liver disease 2010, 14(1):169–176 factors involved in the spread of infection are persons who have their face shaved by street barber or those 10. Department of Ophthalmology Liaquat University of Medi- involved in sexual abuse.11,12,13 cal and Health Sciences Jamshoro from July 2007 to June 2008. Managing Occupational Risks for Hepatitis C Transmission in In our study the frequency of Hepatitis B and C is the Health care setting. Clin Microbiol Rev. 2003; 16: 546-68 2.5% and 3.13% respectively. In other study by Sheikh 11. Luby S. The relationship between therapeutic injections and and his colleagues15 carrier state of HBs Ag was found high prevalence of hepatitis C infection in Hafizabad. Pakistan. Epidemiol Infection. 1997; 119: 349-56 to be 2.8 %. According to Chaudhary and his colleagues 12. Khuwaja AK, Qureshi R, Fatimi Z. Knowledge and attitude the prevalence of hepatitis C was 11.26%.14 In another about hepatitis B and C among patients attending family medi- study done by Weis and his co workers at John Hop- cine clinics in Karachi. Eastern Mediterranean Health J. 2002; 8: kins, 4% patients admitted for surgery had HBV and 13. Thornburn D, Roy K, Camerson SO. Risk of hepatitis C virus transmission from patient to surgeons. Gut 2003; 52; 1333-8.
In our study the prevalence of Hepatitis B and C 14. Chaudhary IA, Khan SA, Samiullah. Should we do the hepati- was more in males (54.31%) than in females (45.68%). In tis B and C screening on each patient before surgery. Pak J Med Sci. 2005; 21; 278-80.
another study done by Naeem and co workers, Hepa- 15. Shaikh MH, Shams K. Prevalence of HBV in health care person- titis B and Hepatitis C prevalence in preoperative cata- nel and methods of control. J College of Physicians and Sur- ract patients was found to be higher in males(59.18%) geons Pak. 1995; 5: 19-21.
16. Makary ESW, Weis MA. Prevalence of blood borne pathogens than females (40.82%).17 Iftikhar et al also showed that in an urban university based general surgical practice. Ann Ophthalmology Update Vol. 13. No. 2, April-June 2015 Incidence of Hepatitis B & C among Admitted Eye Patients in Tertiary Care Hospital of Peshawar Surg. 2005; 24: 803-9 Gomal Journal of Medical Sciences 2006, 4:2.
17. Syed Saad Naeem, Efaza Umar Siddiqui, Abdul Nafey Kazi, 19. Farooqi JI, Farooqi RJ: Relative Frequency of Hepatitis B and Sumaiyatauseeq Khan, Farhan E Abdullah, Idrees Adhi. Preva- Hepatitis Cvirus infections in patients of cirrhosis in NWFP, lence of hepatitis ‘B' and hepatitis ‘C' among preoperative cata- Pakistan. J Coll Phys Surg Pak 2000, 10:217–219.
ract patients in Karachi. BMC research notes 2012; 5(492).
20. Nangrejo KM, Qureshi MA, Sahto AA, Siddiqui SJ: Prevalence 18. Ahmad I, Khan SB, Rehman HU, Khan MH, Anwar S: Fre- of Hepatitis B and C in the patients Undergoing Cataract Sur- quency of Hepatitis B and Hepatitis C among cataract patients. gery at Eye Camps. Pak J Ophthalmol 2011, 27:1 SUBSCRIPTION TO ‘OPHTHALMOLOGY UPDATE'
Your Quarterly ‘Ophthalmology Update' is being regularly published from Islamabad
since 1998. The subscription of the paid members expires by 31st December every year and needs to be renewed immediately, while the new subscribers are welcomed to join the esteemed coterie of our regular members.
Since the journal is fully indexed with Pakistan Medical & Dental Council (PMDC) and Higher Education Commission of Pakistan (HEC) as a standard scientific journal entirely devoted to promotion of Medical Sciences especially to the welfare of visually handicapped. It highlights the most current research, scientific articles, reviews and interesting case reports in all fields of Medicine including Ophthalmology with updated information around the world. Currently, the journal is being subscribed by the doctors practicing in every field of medicine, postgraduates, health professionals including libraries of medical colleges and are making full use of the scientific material. Doctors serving in your institutions can also contribute their research papers, thesis, articles and interesting case reports to the journal. The journal is being printed by a high-class printer of the country on a beautiful English Matt paper and is being published on quarterly basis on the 1st of every ensuing month of the
year. Moreover, the journal is freely distributed to the participants of various conferences being
held from time to time.
Fresh and renewed annual subscription of the journal is Rs.800/- which is very nominal and can
be remitted through money order/cheque/bank draft and on line to A/C: 145-20620-714-126749
maintained at Summit Bank (Code: 145), Markaz F-10, Islamabad in the name of Ophthalmology
Update,
or to the managing editor at 267-A, St: 53, F-10/4, Islamabad. Single copy of the journal is
supplied freely to the principal author on complimentary basis, while the additional copies can be
had on payment of Rs.200/- per copy. Members are ensured regular and uninterrupted supply of
the journal at their doorstep. Our sole motto is SERVICE TO MEDICINE and we assure you our
fullest cooperation with highest considerations for regular and well-in-time supply of the journal.
Wishing you good health, happiness and a prosperous professional life. With profound regards.
Yours sincerely,
Prof. Dr. M. Yasin Khan Durrani
MBBS., DO., MD., FICO(UK)., FRCOphth(Lond)
Editor in Chief
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Visual Outcome & Complications of
Scleral-fixation Posterior Chamber Intraocular Lenses
Mir Ali Shah FCPS. Fellow Vitreo-Retina1, Bilal Khan2, Bilal Khan3 Bilal Bashir4, Sher Akbar Khan5, Mohd Jawad6, Muhammad Idris7 Purpose: To determine the visual outcome and complications of posterior chamber scleral fixation intraocular lenses (PCSF
IOL).
Material and Methods: This retrospective study was carried out in the Department of Ophthalmology, Lady Reading Hospi-
tal, Peshawar from July 2011 to July 2013. A total of 17 patients were included in the study. Details of the patients like age, gender, pre- and postoperative best spectacle corrected visual acuity (BSCVA), indication for surgery and detailed slit-lamp and fundus examination were recorded on a designed proforma. The main outcome measures were postoperative visual acuity (VA) and complications. Patients were followed for one year regarding vision and any complications. All the data was entered and analyzed using SPSS version17. The data was expressed in the form of tables and charts.
Results: A total of 17 eyes of 17 patients were included in this study. 14(82.35%) were males and 3(17.65%) were females
with a male to female ratio 4.6:1. The age ranged from 4 to 15 years and were followed over a period of one year after place- ment of posterior chamber scleral fixation intraocular lenses (PC SF-IOL).14 (82.35%) of the eyes had a gain in VA from CF to 6/9 while 3(17.65%) had no change in the VA. Postoperative complications were observed in 5(29.40%) and included IOL dislocation in one case(5.88%), exposed suture with pyogenic granuloma in 2(11.76%), increased IOP in 1 case (5.88%).
and iris capture in 1(5.88%) eye.
Conclusion: Posterior chamber scleral fixation IOL appear to be a safe technique with minimal complications when there
is no capsular support.
port is a safe procedure with a low risk of complica- While crystalline lens subluxation can occur in any tions in the early postoperative period.2 Suture related patient, these three profiles are most prone: significant complications are unique to PCSF IOL. To avoid ero- blunt trauma to the eye or head; systemic conditions sion of the knots through conjunctiva, scleral flaps can such as Marfan's syndrome, homocystinuria, familial be used to cover the knots.3 The partial thickness scle- ectopia lentis, Weill-Marchesani syndrome, aniridia ral flaps can atrophy over time and expose the proline and Ehlers-Danlos syndrome, hypermature cataract in knot. Endophthalmitis has been reported and remains which zonular support has been lost. Symptoms of lens a real risk in patients undergoing SFIOL.4 The possible subluxation includes visual disturbance from extreme causes of dislocation of these IOLs include suture deg- hyperopic or myopic shift, astigmatism or acquired radation,5 suture breakage,3 slippage of the haptic from aphakia. Acute secondary angle closure glaucoma can the suture,3 or erosion of the suture through the tissue.6 occur due to subluxated lens.1 Children with monocular Recent studies have shown that the implantation of aphakia who become contact lens intolerant require an scleral fixation posterior chamber intraocular lenses is intraocular lens (IOL) for visual rehabilitation. When feasible and renders more favorable results in children there is inadequate support from the posterior lens cap- over 2 years of age if non-compliant with spectacles or sule, use of an anterior chamber IOL(AC IOL) or PCS- contact lenses.7,8 Implantation of IOLs in children less FIOL may be considered. The authors reported their ex- than 2 years is still controversially discussed.9,10 There- perience with scleral fixation of posterior chamber IOLs fore, we have performed a study to compare the out- in children. Implantation of a PCSF IOL for the surgical comes of secondary intraocular lens implantation in management of aphakia in the absence of capsular sup- aphakic eyes of children older than 2 years previously 1Associate Professor, Department of Ophthalmology, PGMI Lady operated for traumatic and congenital cataracts.
Reading Hospital Peshawar. 2,4,5Resident,Vitreo-Retina. 3Resident Neuro Surgery. 6Postgraduate Trainee Department of Ophthalmology, Anterior-chamber lenses were used for many years Lady Reading Hospital, Peshawar. 7Medical Officer Ophthalmology, because of relatively easy implantation technique, even Lady Reading Hospital Peshawar. in the total absence of capsular support. However, the Correspondence: Dr. Mir Ali Shah, Associate Professor, Department fixation in the anterior-chamber angle may cause glau- Ophthalmology, Lady Reading Hospital, Peshawar. Email: Cell: 03005948091 coma and chronic irritation to the iris. Furthermore, long-term endothelial cell loss with corneal decompen- Received: December 2014 Accepted: January 2015 sation is reported for angle-fixated intraocular lenses, Ophthalmology Update Vol. 13. No. 2, April-June 2015 Visual Outcome & Complications of Scleral-fixation Posterior Chamber Intraocular Lenses as well as for iris claw lenses fixed to the anterior sur- PC-IOL. All eyes had a PMMA IOL implanted. About face, a technique introduced by Jan Worst almost 30 14 (83.33%) of the eyes had a gain in VA from CF to 6/9 while 3(16.66%) had no change in the VA. Postopera- MATERIAL AND METHODS
tive complications were observed in 5(29.40%) and in- It is a retrospective study carried out in the De- cluded IOL dislocation in one case(5.88%), exposed su- partment of Ophthalmology, Lady Reading Hospital, ture with pyogenic granuloma in 2(11.76%), increased Peshawar from July 2011 to July 2013. A total of 17 pa- IOP in 1 case (5.88%).and iris capture in 1(5.88%) eye tients of PCSF-IOL were included in the study. Details (Figure 2). The one eye with dislocation of IOL required of the patient like age, gender, pre- and postoperative repeat surgery.
best-corrected visual acuity (BCVA), indication for sur- gery and detailed slit-lamp and fundus examination were recorded on a designed proforma . Visual acuity was tested using standard Snellen visual acuity chart along with best spectacle corrected visual acuity. The main outcome measures were final BCVA and postop- erative complications. Patients were followed for one year regarding vision and any complications like raised intraocular pressure (IOP), IOL decentration and su- ture breakage. All the data was entered and analyzed using SPSS version17. The data was expressed in the form of tables and charts. Surgical technique: After doing all the essential pre-
operative investigations; the patients were subjected to surgery either under local or general anesthesia based on individual patient. A scleral tunnel incision centered at the 3 and 9 o' clock positions, with a width of 3-4 mm, was made in all cases. A double-armed 9/0 polypropyl- ene suture with one end straight and the other curved needle was used. One straight needle was passed per- pendicularly through the sclera, 1.5 mm behind the limbus at 3 o' clock position in a direction parallel to the iris, and was retrieved in the hollow of a 26-G needle on the opposite side. The stretched prolene suture was pulled out of the eye through a previously made scleral tunnel. The suture was then cut in the middle, and the two suture ends were passed through the correspond- ing eyelet of the SFIOL and tied. The lens was then inserted into the ciliary sulcus, and the sutures pulled and tied to the partial sclera of the tunnel on both sides The lens is supported in a normal eye by zonules, below the scleral flap to avoid its exposure and to se- cure the IOL. The scleral wound was closed with inter- while support for an IOL is provided by posterior cap- rupted vicryl 7/0 suture or 10/0 nylon. The suture was sule and zonules. When there is no capsuler support covered by the conjunctiva. The IOLs implanted were or lack of zonular support, then IOL can be placed be- single-piece polymethyl-methacrylate (PMMA) lenses tween the iris and cornea in anterior chamber with open with eyelets(Neo eye). The optic diameter was 6.5 mm or closed loop.11 It can be placed in the ciliarry sulcus as and the overall diameter was 13 mm.
iris fixated or it can be fixated to sclera in the posterior chamber.11,12,13 The gender distribution in our series was A total of 17 eyes of 17 patients included 14(82.32%) a male to female ratio of 4.6:1. There has been an in- males and 3(17.68%) females with a male to female ratio crease in the gender of the male patients resulting from 4.6:1 (Figure 1).
an increased trauma in Pakistan, increase incidence in The age ranged from 4 to 15 years and were fol- the male gender has been reported in by Ferriera JL22 lowed over a period of one year after placement of SF- et al and Banayoun Y et al.23 In our study the mean age Ophthalmology Update Vol. 13. No. 2, April-June 2015 Visual Outcome & Complications of Scleral-fixation Posterior Chamber Intraocular Lenses was 8 yrs and they enjoyed good vision for at least one lar/capsular support is the sclera. It is the strongest in- year follow up. The mean age reported was from 8.6 traocular tissue, mainly avascular, and does not have a years to 10.5 years reported by Bhutto IA15 and Ganesh tendency toward inflammation.13 A et al16.About 14 (83.33%) of the eyes had a gain in VA For iris claw lenses, uveitis–glaucoma–hemor- from CF to 6/9 while 3(16.66%) had no change in the rhage syndrome has been reported and late dislocations VA. The reported range in the improvement in the VA may occur. Should vitreoretinal surgeons choose to use has been 53.6% by Kumar et al20,17 this type of lens, I would recommend the retropupil- Complications in our study included temporarily lary reverse implantation technique.21 This technique elevated IOP unrelated to the IOL insertion, which is in is much more convenient because it prevents contact 1(5.88%) and PCIOL subluxation requiring revision sur- with the corneal endothelium intraoperatively, ie, dur- gery in 1/17 eyes (5.88%). This low rate may, of course, ing fluid-air exchange and postoperatively due to eye increased in the following years, a fact, which has been rubbing, blinking etc.13 published recently.14 Complications encountered in our study are comparable with those seen in other pediat- Posterior chamber sclera fixation IOL implanta- ric scleral-fixated PC IOL studies, and retinal problems tion is a safe technique with minimal complications arising from the procedure or endophthalmitis due to a when there is no capsular for visual rehabilitation espe- fistula have not been encountered.19,20 cially in children.
Erosion, breaking or wearing away of the 10×0 REFERENCES
polypropylene thread is of some concern, since it has 1. LuoL, LIM,Zong Y, Cheng B, Liu X. Evaluation of second- been shown that fibrous reactions around the IOL hap- ary glaucoma associated with subluxated lens misdiag- nosed as acute primary angle closure glaucoma.J Glauco- tics is lacking.21,22 In our study there is breakage of su- ture and dislocation of only one(5.88%) IOL and we did 2. Luk As,Young Al,Cheng Ll. Long-term outcome of scleral- his second surgery for SF IOL.In an observational case fixated intraocular lens implantation.Br J Ophthalmolol.2013 series by Vote et al., 17 eyes (27.9%) had spontaneous Lewis JS. Abexternosulcus fixation. Ophthalmic Surg. 1991; suture breakage with several eyes having multiple epi- 4. Heilskov T, Joondeph BC, Olsen KR, Blankenship GW. Late en- sodes.23 the discrepancy between his and our study is dophthalmitis after transscleral fixation of a posterior chamber due to the increase in sample size and long term follow intraocular lens. Arch Ophthalmol.1989;107:1427.
up by him(4 months vs 3 years). Drews, in his report Price MO, Price FW, Jr, Werner L, Berlie C, Mamalis N. Late dislocation of scleral-sutured posterior chamber intraocular noted that polypropylene may fail after a prolonged lenses. J Cataract Refract Surg. 2005;31:1320–6.
period in the eye. The deterioration was most marked Kim J, Kinyoun JL, Saperstein DA, Porter SL. Subluxation of with sutures buried in actively metabolizing ocular tis- transscleral sutured posterior chamber intraocular lens (TSI- OL) Am J Ophthalmol. 2003;136:382–4.
sue.22 there has been a wide range of the incidence in Sharpe MR, Biglan AW, Gerontis CC. Scleral fixation of poste- the literature by various authors from 9.09% to 14.28% rior chamber intraocular lenses in children. Ophthalmic Surg as shown in table 1. Other complications in our study Ahmadieh H, Javadi MA. Intraocular lens implantation in chil- were IOL dislocations, iris capture, increased IOP and IOL dislocation; table 1 shows a comparison of compli- Lambert SR, Lynn M, Drews-Botsch C, et al. A comparison of cations in our study and that reported by other authors.
grating visual acuity, strabismus, and reoperation outcomes among children with aphakia and pseudophakia after unilat- eral cataract surgery during the first six months of life. JAA- Table-1: A comparison of various
complications seen in our study and that reported
10. Lithander J. Prevalence of amblyopia with anisometro- by various other authors around the globe
pia or strabismus among schoolchildren in the Sultanate of Complications In our study (%)
In literature (%)
Oman. ActaOphthalmol Scand. 1998;76(6):658–662.
11. Lithander J, Sjóstrand J. Anisometropic and strabismicamblyo- 11% by Buckley EG14 et al pia in the age group 2 years and above: a prospective study of 9.09% By Kumar et al20 the results of treatment. Br J Ophthalmol.1991;75(2):111–116. 3.5% by Narang P et al21 12. Lindquist TD, Agapitos PJ, Lindstrom RL, et al. Transscleral 16.66% by Zou Y et al19 fixation of posterior chamber intraocular lenses in the absence 7.1% by Ganesh A et al16 of capsular support. Ophthalmic Surg.1989;20:769–775.
Glaucoma / suture 13. Scharioth BG. IOL fixation techniques. Retinal Physi- 18.18% by Kumar M et al20 14.28% by Sharpe MR et al7 14.28% by Sharpe MR et al 14. fixated (sutured) posterior chamber intraoc- 1999;3(5):289-94.
10.70% by Ganesh A et al16 15. IA, GQ, Mahar PS, QidwaiUA.Visual outcome and 9.09% by Kumar M et al20 complications in Ab-externoscleral fixation IOL in aphakia in pediatric age group. Pak J Med Sci. 2013; 29(4): 947–50.
We are convinced that the best place for fixation of intraocular lenses in the absence of sufficient zonu- Ophthalmology Update Vol. 13. No. 2, April-June 2015 Visual Outcome & Complications of Scleral-fixation Posterior Chamber Intraocular Lenses Chamber Intraocular Lenses in Amblyopic Aphakic Children. Middle East Afr J Ophthalmol. 2008; 15(2): 61–5.
21. P, Narang S. Glue-assisted intrascleral fixation of pos- 17. Rehman A,Bhutto IA,Bkhari S,Hassan M,Bhatti MN.Pak J Oph- terior chamber intraocular lens. Indian J Ophthalmol 2013; 61(4): 163–7.
18. Lithander J. Prevalence of amblyopia with anisometro- 22. FerreiraJL, F. VeginiF, MaliskaCR. Clove hitch knot for scleral pia or strabismus among schoolchildren in the Sultanate of fixation of dislocated IOL – with temporary externalization of Oman. ActaOphthalmol Scand. 1998;76(6):658–62.
the haptics through a clear cornea incision. Invest Ophthalmol 19. Drews RC. Quality control, and changing indications for lens Vis Sci 2004;45: E-Abstract 330.
implantation. The Seventh Binkhorst Medal Lecture-1982. Oph- 23. Benayoun Y, Petitpas S, Turki K, Adenis J, Robert P. Suture- less scleral intraocular lens fixation: Report of nine cases and 20. Scleral-fixated intraocu- literature review; 2013; First Announcement KAROPHTH 2015
6th, 7th, 8th March 2015 Pearl Continental Hotel, Karachi Last Date for Abstract Submission For Further Information, Registration, Abstract submission Quiz competition and video session Please contact: Mr. Muhammad Usman Tariq 0306-7484544 OSP Office, PMA House,Agha Khan III Road Karachi.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Prevalence and Density of Amblyopia in
Strabismic Patients of School Age Children
(A study of 106 cases)
Mohammad Alam FCPS1, Misbah Durrani FCPS2 Prof. Lal Mohammad FCPS3, Irfan Ullah Khan FCPS4 Objective: To find out the prevalence and density of amblyopia in strabismic patients of school age children.
Materials and methods: This prospective study was conducted in eye care centre Karak and Jan eye clinic Kohat from
June 2013 to June 2014 with the objective to know the prevalence and density of amblyopia in school age children with strabismus. School age children with strabismus from age range of 5-15 years were included in the study. Visual acuity was checked with Snellen chart. Anterior segment and posterior segment examination was done with direct and indirect ophthalmoscope and slit lamp. Retinoscopy with cycloplegia was done to find out refractive error. Strabismus was assessed with Hirschberg and cover-un cover test. Amblyopia was recorded as mild of 2 lines difference, moderate 3 lines difference while more than 3 lines was graded as severe amblyopia. Total 106 school age children with strabismus were included in the study. Children with co.ocular morbidity except strabismus and refractive error were excluded from the study.
Results: All patients were from age range of 5-15 years with mean age of 7.8 years. Out of 106 patients 68 (64.15%) were
male and 38 (35.84%) were female. 81 (76.41 %) patients had esotropia out of which 63 (77.77%) had uniocular while 18 (22.22%) had alternating esotropia. 25 (23.58%) patients had exotropia out of which 19 (76%) had uniocular while 6 (24%) had alternating exotropia. In uniocular esotropic 63 patients, 60 (95.23%) patients had amblyopia. The density of amblyopia was mild in 34 (56.66%). moderate in 21 (35%) and severe in 5 (8.33%) of uniocular esotropic group. In alternating esotropic group out of 18 patients 7 (38.88%) had amblyopia in which mild was present in 6 (85.71) and moderate in 1(14.28%). 25 patients were exotropic out of which 19 patients had uniocular exotropia while 6 patients had alternating exotropia. In 19 uniocular exotropic patients, 14(73.68%) patients had amblyopia in which 9 (64.28%) patients had mild,3(21.42%) had moderate while 2 (14.28%) had severe amblyopia. In alternating exotropic group out of 6 patients 5(83.33%) had mild while 1(20%) had moderate amblyopia. Most of the amblyopic patients had hypermetropia .
Conclusion: Strabismus is a common cause of amblyopia in children. Early screening and management of school age
children is necessary to prevent amblyopia.
Key ward: Esotropia, Exotropia, Amblyopia
has shown a strabismus prevalence of 3% and amblyo- Strabismus and amblyopia are two most common pediatric ocular disorders with cosmetic and functional In developed countries policies are being formu- sequale. Amblyopia is associated with suboptimal vi- lated for early detection of strabismus and amblyopia.5 sion despite best correction with refraction. In the ab- In Japan children are assessed for strabismic amblyopia sence of any other ocular or neural morbidity strabis- in early age primarily by pediatrician and after 6 years mus is the misalignment of the two eyes which in case by ophthalmologist.6 Early detection and treatment of of failure of treatment may result in loss of binocularity strabismus and amblyopia are very important. But in and depth perception1 Failure to diagnose and manage developing countries like Pakistan, children with stra- amblyopia in early age may result in lifelong visual im- bismus present later. According to a local study most pairment.2 Strabismic amblyopia is a serious blinding of children with squinting eyes presented after 5 years condition affecting the patients in early life. Popula- of age.7 In comparison to this in developed countries tion-based prevalence estimates in children range from presentation is early. Some studies have revealed pres- 0.3% to 4.4% strabismic amblyopia.3 Hispanic / Latino entation of squinting patients at the age of 2 -5 years.8,9 children age of 5 -14 years assessing study in Colombia No reliable data is available in our country and 1Assistant Professor Ophthalmology KMU Institute of Medical Sci- again there is many differences in data in various stud- ences, K.D.A, Kohat. 2Assistant Professor, Radiology, Bacha Khan Medical College, Mardan. 3Professor of Ophthalmology, KMU Insti- ies due to demographic, geographical, social, educa- tute Of Medical Sciences, K.D.A, Kohat. 4Refractionist, K.D.A Teach- tion and cultural influences over the community. This ing Hospital, Kohat. study was done to find out the prevalence and density Correspondence: Dr. Mohammad Alam1 Assistant Professor Ophthal- of amblyopia in strabismic patients of school age chil- mology KMU Institute of Medical Sciences K.D.A dren. Then it will be possible for the early detection and management as well as making the people aware of this Received: December 2014 Accepted: February 2015 grave problem.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Prevalence and Density of Amblyopia in Strabismic Patients of School Age Children MATERIALS AND METHODS
opia was present in 9 (64.28%) patients, moderate in 3 This prospective study was conducted in eye care (21.42%) patients and 2 (14.28%) had severe amblyopia. centre Karak and Jan eye clinic Kohat from June 2013 In alternative exotropia out of 6 patients 5 (83.33%) had to June 2014 with the objective to know the prevalence amblyopia. In amblyopic patiens 4 (80%) patients had and density of amblyopia in strabismic school age chil- mild while 1(20.0%) had moderate amblyopia. Table II dren with age range of 5 – 15 years with mean age of 7.8 years. A proper proforma was designed. Consent Table-I: Gender distribution no. 106
was taken from the parents/guardians of the children. No of Patients
Children from age 5 -15 years were included in the study. Anterior and posterior segments examination was done with direct/indirect ophthalmoscope and slit lamp. Squint was assessed with Hirchberg test and Table-II: Showing types of strabismus
cover un cover test.
TYPES OF STRABISMUS SUB TYBE
Visual acuity was checked with snellen's Chart. Cycloplegic refraction was done with retinoscope. Am- Group I Esotropia No. 81 blyopia density was graded as mild difference of two Group II Exotropia No. 25 lines, moderate difference of 3 lines and severe with difference more than 3 lines. Inclusive criteria was chil- dren of age 5 -15 years suffering from strabismus while Strabismus and amblyopia are the most common children with other ocular diseases except squint were ocular conditions during school age children. Strabis- excluded from the study. Total 106 children with age mus is significant cause of amblyopia and psychosocial range of 5 -15 years with mean age of 7.8 years were in- distress.Various studies have proved strabismus to be cluded. Out of 106 patients 68 (64.15%) were male and the most common cause of amblyopia.10,11 Other causes 38 (35.84%) were female (Table I). On basis of squint the of amblyopia are anisometropia, sensory deprivation children were divided into two groups. Group I had and combined pattern.12 Our study was conducted on esotropic and Group II had extropic patients.
106 strabismic school age children for the prevalence and density of amblyopia. 81(76.41) patients were es- Out of 106 patients, 81 (76.41%) children had eso- otropic while 25 (23.58%) were exotropic. Male were tropia (Group 1) while 25(23.58%) had exotropia(Group more than female. Amblyopia was 95.23% in uniocular II). In esotrpic group 63 (77.77%) had uniocular while esotropic patients with density of mild, moderate and 18 (22.22%) had alternating esotropia. Group II had 25 severe in descending pattern and in 38.88% patients exotropic patients out of which 19 (76%) had uniocular with alternating esotropia.
while 6 (24%) had alternating exotropia. Table II In total In exotropic group of uni ocular 19 patients, 14 106 patients, 86 (81.13%) had amblyopia with subdivi- (73.68%) patients had amblyopia with mild, moderate sion in different groups and sub groups, the density of and severe density going down. In alternating exotrop- amblyopia is as follow. In uniocular esotropic 63 pa- ic group out of 06 patients 5(83.33%) patients had am- tients, 60 (95.23%) patients had amblyopia in which 34 blyopia with mild form four- fold more than moderate (56.66%) had mild, 21 (35%) moderate and 5 (8.33%) density.The results of different studies are different due had severe amblyopia. In alternating esotropia, out to multiple factors like education, demographic pat- of 18 patients 7 (38.88%) patients had amblyopia. Out tern, geographic, culture dependence and awareness. which 6 (85.71%) had mild amblyopia while 1 (14.28%) Variation of results are also present in national and in- had moderate amblyopia.
In uniocular exotropic group, out of 19 patients 14 Mian M Shafique, Naeem Ullah, H Nadeem have (73.68%) patients had amblyopia in which mild ambly- reported amblyopia in 82% of esotropia. They have Table-III: Showing prevalence and density of amblyopia
No of Patients No of Amblyopic (%)
Moderate (%)
Severe (%)
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Prevalence and Density of Amblyopia in Strabismic Patients of School Age Children reported amblyopia more dense in uni ocular squint Philadelphia: Lippincott Williams & Wilkins; 2008. p. 325-244.
and was common in esotropia than exotropia.13 Presian Greeberg AE ,Mohney BG etal.Incidence and types of child- hood esotropia.A population based study.Ophthalmology MW, Novak A, have reported in Baltimore Study am- blyopia more common in exotropia than esotropia.14,15 Rodriguez MA,Castro GM.Visual health of school children in Kvarnstrom G, Jakobsson, D have reported in their Medellin,Antioquia Colombia{in Spanish}Bol Oficina Sanit Pan- study that 44% of amblyopic patients were due to stra- am 1995;119:11-4.
Committee on Practice and Ambulatory Medicine Section on bismus.16 Ebans Mvogo C, Ellog A etc conducted study Ophthalmology, American Association of Certified Orthop- on prevalence of amblyopia in strabismic children. tists, American Association for Pediatric Ophthalmology and According to their study, they reported amblyopia in Strabismus, American Academy of Ophthalmology: Eye ex- amination in infants, children, and young adults by pediatri- 80.46% in esotropia and 54.40% in exotropia. Matsuo T, cians. Organizational princi ples to guide and define the child Matsuo C have reported in their study high prevalence health care system and/or improve the health of all children. of amblyopia in school age children but according to Ophthalmology (2003) 110: 860-865.
Matsuo T, Matsuo C, Matsuoka H and Kio K: The detection of their study strabismic amblyopia was more common in strabismus and amblyopia at 1.5- and 3-year-old children by intermittent exotropia.17 Ahmad-M, Iqbal S, Jhangir N, pre school vision-screening program in Japan. Acta Med Okay- have reported in their study on patients of strabismic ama (2007)61: 9-16.
Shah MA,Khan.S,Mohammad.S.Presentation of childhood amblyopia. According to their study 71.79% patients squint.J Postgrad Med Inst. Jun 2002; 16:206-10.
with strabismus had amblyopia and in esotropia the Mohney BC,Greenberg AE,Diehl NN.Age at strabismus di- amblyopia was more prevalent-as well as more dense agnosis in an incidence cohort of children.Am J Ophthalmol than exotropia.18 Our study is being supported by re- Graham PA. Epidemiology of strabismus.Br J Ophthalmol sults of other national and international studies. Sethi S has reported amblyopia in 55% strabismic patients.19 10. Sala NA. Amblyopia and Strabismus. Pa Med. 1996; 99:63-6.
11. Pediatric Eye Disease investigator group. The clinical profile Wood Ruff etal has reported in their study that 57% of moderate amblyopia in children younger than 7 years Arch amblyopia was due to strabismus.
Ophthalmol. 2002; 120:281-7.
12. Lithander J. Prevalence of amblyopia with anisometropia or strabismus among school children in the Sultanate of Oman. Strabismus and amblyopia are common ocular Acta Ophthalmol. 1998; 76:658-62.
problems in children. Their identification and diag- 13. Shafique MM,Ullah N, Nadeem HB et al.Incidence of Amblyopia nosis is necessary in early life which is very sensitive in Strabismic Population.Pak J Ophthalmol 2007,Vol 23 NO 1. 14. Preslan MW, Novak A. Baltimore Vision Screening Project. stage in children. A comprehensive screening program should be formulated and applied for management. 15. Preslan MW, Novak A. Baltimore Vision Screening Project. All children in play group or on entry into school may Phase 2. Ophthalmology. 1998;105(1):150- be necessarily examined to give them rid of their prob- 16. Kvarnstrom G, Jakobsson P, Lennerstrand G. Visual screen- ing of Swedish children: an ophthalmological evaluation. lems of amblyopia and strabismus.
Acta Ophthalmol Scand. 2001; 79(3):240-4.
17. Matsuo T,Matsuo C .The prevalence of strabismus and amblyo- CarltonJ, KarnonJ, Czoski-Murray C, Smith KJ, MarrJ. The clini- pia in Japanese elementary school children.Ophthalmic Epide- cal effective and cost-effectiveness of screening programs for ambly opia and strabismus in children up to the age of 4-5 18. Ahmed M,Iqbal S,Jehangir N. Amblyopia in strabismic chil- years; a systemic review and economic evaluation. Health Tech- dren .Ophthalmology Update .Jan-March 2012 Vol.NO I.
nol Assess. 2008;12(25):1-194.
19. Sethi S ,Hussain I, SethiMJ. Causes of amblyopia in chil- Scheiman M, Wick B. Clinical Management of Binocular Vision: dren coming to ophthalmology OPD KTH Peshawar. JPMA Heterophoric Accommodative and Eye Movement Disorders. Ophthalmology Update Vol. 13. No. 2, April-June 2015 Tuberous Sclerosis Complex
Hussain Ahmad Khaqan FCPS, FRCS1, Farrukh Jameel MBBS2 Hadia Jabeen MBBS3, Muhammad MBBS4, Usman Imtiaz MBBS5 when one major and one minor criteria are detected Tuberous sclerosis complex (TSC) is an autoso- Only one major feature or two or more minor criteria mal dominant neuro-cutaneous disease (phacomatosis) without any major feature mentions the possibility of The incidence of tuberous sclerosis.
the disease is approximately 1/6000- 1/10000.Diag- Ocular manifestations of TSC including retinal nosis is based on clinical and para-clinical criteria de- hamartomas occur in less than 50% of the patients and fined by the tuberous sclerosis consensus conference are bilateral in one third of the cases. There is no cor- in 1998. There are two groups of symptoms including relation between age and ocular manifestations.
major and minor criteria. The major criteria consist of: Facial angio-fibromas or forehead plaques, Non-trau- Case series identified 5 eyes of three patients over matic ungula or periungual fibroma, Hypo-pigmented the period of 3 months from May 2013 to July 2013 (age macules (more than 3), Shagreen patch, Cortical tubers, range 8 years to 42 years). 1 of the patients was referred Sub-epandymal nodules, Sub-epandymal giant cell as- from neurosurgery department of Lahore General trocytoma, Multiple retinal nodular hamartomas, Car- Hospital, after complaining of seizures and decrease diac rhabdomyoma, Lymphangio-myomatosis and re- vision, that patient had retinal Astrocytomas and sys- temic findings sebaceous adenomas, ash leaf spots, sub Posterior Segment OU Retinal Astrocytomas OD Retinal Astrocytomas OD Retinal Astrocytomas • Ash leaf spots • Sub ungal hemartoma Systemic manifestations • Small angio-lipomas over both kidneys • Multiple calcified foci in sub- • Sebaceous adenomas The minor criteria include: Dental Pits (more than 14), ungal hemartoma, small angio-lipomas over both kid- Hamartomatous rectal polyps, Bone cysts, Cerebral neys, multiple calcified foci in sub-ependymal region white matter radial migration lines, Non-renal hamar- on initial examination. 1 patient was the sibling of the tomas, Retinal achromatic patch, Confetti skin lesions, patient who also had retinal Astrocytomas. 3rd patient Multiple renal cysts. When there are two major criteria was the mother of the patients who had right retinal or one major and two minor criteria the diagnosis is es- tablished as definite TSC. The term probable TS is used Table 1 summarizes the case of all three patients with 1Consultant Ophthalmologist & Retinal Surgeon, Lahore General Hos- their age, visual acuity on presentation, initial investi- pital / PGMI, Lahore. 2,3,4Postgraduate Trainees, Lahore General Hos- gations, examination findings, fundus findings pital / PGMI, Lahore. 5Resident Alshifa Trust Eye Hospital, Rawalpindi Patient " A"
Correspondence: Dr. Hussain Ahmad Khaqan Department of Oph- A child 8 years/male, presented in Eye-OPD on thalmology, Lahore General Hospital / PGMI, Lahore. House No. 87, Eden Canal Villas, Canal Bank Road, Thokar Niaz Baig, Lahore. 1st July, 2013 for the assessment of fundus, referred by some neuro-physician. He has history of fits for 2years Cell: +92-300-4270233, Fax:+92-42-7223039 and spontaneous muscular spasm over Left arm, for Received: December 2014 Accepted: January 2015 which he was given medication by the neurophysician. Ophthalmology Update Vol. 13. No. 2, April-June 2015 Tuberous Sclerosis Complex His fits and muscular spasm were controlled. He has no Patient "B"
family history of fits. He has 3 siblings (all boys). Both This patient was the mother of patient "A"she was of his parents were alive and healthy 42 y of age. She was screened for any signs and symp- toms of tuberous sclerosis. after examination she was found having right retinal astrocytomas without any Anterior segment was normal systemic manifestations Posterior segment showed bilateral retinal astrocytomas Systemic Evaluation revealed
• Ash leaf spots • Sub ungal hemartoma • Small angiolipomas over both kidneys • Multiple calcified foci in sub-ependymal region • Sebaceous adenomas Right fundus
Left fundus
Sebaceous adenomas
Ash leaf spots
Patient "C"
This patient was the brother of patient "A" 8 y of age. She was screened for any signs and symptoms of tuberous sclerosis. after examination she was also found having right retinal astrocytomas without any systemic manifestations Sub ungal hemartomas
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Tuberous Sclerosis Complex able ocular and systemic manifestations 3 patients were evaluated for Tuberous Sclerosis REFERENCES
manifestations(ocular and systemic). 2 patients were male siblings and 1 was the mother. only 1 patient Para clinical Manifestations of Tuberous Sclerosis ran J Child showed both ocular and systemic features. 2 patients Neurol. 2012 Summer; 6(3): 25–31 Staley BA, Vail EA, Thiele EA. Tuberous sclerosis complex: showed only Ocular features. this shows strong inherit- diagnostic challenges, presenting symptoms, and commonly ance pattern and that the Tuberous Sclerosis complex missed signs. Pediatrics. 2011 Jan;127(1):e117–25 does not necessarily shows systemic manifestations.
Thiele EA, Korf BR. Phakomatoses and allied conditions. In: Swaiman KF, Ashwal S, Ferriero DM, editors. Swaimans pedi- atric neurology. 5th ed. China: Elsevier Saunders; 2012. pp. Tuberous Sclerosis although is a rare having vari- Authors of articles and the subsribers are requested to collect the copies of Ophthalmology Update from representatives of the concerned area according to the following: Divisional Manager Peshawar Div.
Divisional Manager Rawalpindi Div.
Regional Sales Manager Sr. Divisional Manager Faisalabad Div.
Sr. Divisional Manager Sr. Divisional Manager Karachi Div.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Association of Anemia with Diabetic Retinopathy
in Patients with Type II Diabtese Mel itus
Mohammad Kashif BVS, MPH1,Nazia Sultan BVS2 Mohammad Arshad Raza FCPS3 ABSTRACT:
Aims/Objectives:
(1) To evaluate the association between anemia and diabetic retinopathy (DR) including non proliferative
DR (NPDR), proliferative DR (PDR) and diabetic macular edema (DME) in Type II Diabetes Mellitus (T2DM).
(2) To identify anemia as an independent risk factor for DR in diabetic patients without significant renal dysfunction.
(3) To correlate the severity of anemia with the severity of DR.
Materials and Methods: In this case control study 170 DM patients (85 cases and 85 controls) above 40 years of age were
included. All patients underwent stereoscopic fundus photography and if present the severity of DR was classified according to International Clinical Diabetic Retinopathy and Disease Severity Scale, cases were divided into 3 groups, NPDR, PDR and DME, while patients with normal fundus were included in control group. All patients underwent complete blood count (CBC) for hemoglobin estimation for detection of anemia. The statistical analysis was done using SPSS version 20. T-test and chi-square test were used for odd ratios and comparisons.
Results: In the present study anemia was seen 38.8% in cases and 11.1% in controls (p<0.0001). 66.6% patients with
severe NPDR and 45.8% with PDR had anemia (P < 0.0001). Odd ratio for anemia in cases and controls was 3.86, and for NPDR, PDR and DME was 3.6, 5.1, 3.0 respectively at 95% of Confidence Interval. The mean hemoglobin level in cases and controls was 10.3+3.2 and 13.6+1.35 g/dl (p<0.0001 ).
Conclusion: The results showed that T2DM patients with DR had lower level of Hb and severity of anemia was positively
co-related with severity of DR. It is suggested that the level Hb should be evaluated periodically in diabetic patients.
Key words: Anemia, diabetic retinopathy (DR), Type 2 diabetes mellitus (T2DM).
function, eventually leading to ß-cell failure.
Diabetes Mellitus (DM) is one of the leading caus- Diabetic Retinopathy (DR) is the most common micro es of morbidity and mortality around the globe and is vascular complication of DM and it remains a leading responsible for 3.8 million deaths per year.1 Its preva- cause of legal blindness and visual impairment in the lence has shown an exponential rise worldwide in the working-age population in the developed world. There last two decades from 30 million cases in 1985 to 177 has been a surge in the T2D-related Diabetic Retinopa- million in 2000.2 The estimated number of patients with thy in the last 2 decades, especially in Asian popula- DM worldwide for 2010 was 285 million which is pro- tion. Studies using retinal photography consistently jected to increase to 439 million by 2030.3 The Interna- suggested that the prevalence of DR is close to 40%, and tional Diabetes Federation (IDF) ranks Pakistan 7th in sight-threatening DR (STDR) accounts for 6-8% of all the list of prevalence of DM.1 At least 171 million peo- diagnosed cases. ple worldwide have DM and this figure is likely to be Diabetic Retinopathy: It is the characteristic group of
doubled by the year 2030. About 50% of persons with lesions found in the retina of individuals who have DM are unaware of the condition and about 2 million DM for several years. It is considered to be the result deaths every year are attributable to this complication of vascular changes in the retinal circulation, a micro- of DM.2 Diabetic mellitus type 2 (T2DM) is character- angiopathy that exhibits features of both micro vascu- ized by peripheral insulin resistance, impaired regula- lar occlusion and leakage.14 DR is a progressive condi- tion of hepatic glucose production and declining ß-cell tion with micro vascular alterations that lead to retinal ischemia, retinal permeability, retinal neo-vasculariza- 1Senior Optometrist, Pakistan Institute of Community Ophthalmol- tion and macular edema. If left untreated patients with ogy Hayatabad Medical Complex, Peshawar. 2Trainee Optometrist Pakistan Institute of Community Ophthalmology Hayatabad Medical DR can suffer severe visual loss. DR is asymptomatic in Complex,Peshawar. 3Eye Specialist, District Head Quarter Hospital, early stages of the disease, but as the disease progresses Nowshera, KPK. symptoms may include blurred vision, floaters, fluctu- Correspondence: Mohammad Kashif MPH. Senior Optometrist- ating vision, distorted vision, dark areas in the vision, Faculty Member, Pakistan Institute of Community Ophthalmol- poor night vision, impaired color vision, partial or total ogy Hayatabad Medical Complex, Email: loss of vision. The risk factor that results in develop- ment and severity of DR include duration of DM, poor Received: December 2014 Accepted: February 2015 metabolic control, hypertension, hyperlipidemia, preg- Ophthalmology Update Vol. 13. No. 2, April-June 2015 Association of Anemia with Diabetic Retinopathy in Patients with Type II Diabtese Mellitus nancy, obesity, smoking, cataract surgery and anemia.16 teria was applied: Anemia in type 2 diabetes mellitus. Anemia, the most
• Patients with history of malignancy, blood loss common blood disorder, is more prevalent in persons during the past three months.
with DM than in persons without diabetes. Anemia is • Hypertension: systolic pressure > 140 mmHg and a below normal level hemoglobin in the blood.21 WHO diastolic pressure > 90 mmHg.
defines anemia as Hb less than 12g/dl in women and • Hyperlipidemia: low density lipoprotein LDL > less than 13g/dl in men. Using this definition, nearly 1 in 4 (23%) patients with Type2DM are anemic. The • Poor Diabetic control: Fasting blood sugar FBS > prevalence of anemia in DM patients is reported as 14- 200mg/dl and Random blood sugar RBS > 250 Etiology of Anemia in Type 2DM
• Obesity: body mass index > 30 kg/m2.
• Diabetic neuropathy affects the central nervous • Renal failure: creatinine >1.5 mg/dl.
systems anemia response.
• Cataract surgery.
• Nutritional deficiencies (low levels of iron or low levels of certain vitamins that body needs to pro- In this case control study, 85 diabetic retinopathy duce Hb and make healthy red blood cells).
patients (cases) and 85 normal retinal subjects (con- • Medications for DM and related conditions.
trols), were analyzed to study the association of anemia Anemia is an independent risk factor for the de- with diabetic retinopathy in type 2 diabetes mellitus. velopment and progression of cardiovascular compli- In the control group there were 34 (40%) males and 51 cations and heart failure, chronic renal disease and DR (60%) females, with a mean age of 53.5± years, duration in DM patients.25 Anemia has been associated with the of DM 9.98± years, Creatinine 0.93± mg/dl. In the case development and progression of both micro vascular group NPDR was present in 43 (50.6%) patients, with (i.e.; DR) and macro vascular complications of DM. a mean age of 53.4 + 9.0 years,(44.2%) were males and Anemia can lead to falsely low HbA1c levels, which 24 (55.8%) females. PDR was present in 24 (28.2%) pa- may result in under treatment of hyperglycemia, which tients with a mean age of 54.9+7.4 years, 9 (37.5%) males in turn will contribute to the progression of both micro and 15 (62.5%) females. DME was present in 18 (21.2%) vascular and macro vascular complications.21 Individu- patients with a mean age of 51.8+8.0 years, 11 (61.1%) als with anemia were more likely to develop DR than individuals without anemia, perhaps because of ane- males and 7 (38.9%) females. By sub categorizing NPDR mia-induced retinal hypoxia. Hypoxia may alter angio- group, 14 (32.6%) patients had Mild NPDR, 17(39.5%) genesis, capillary permeability, vasomotor response, had moderate NPDR and 12 (27.9%) had severe NPDR. and retinal cells survival.
In patients with DME, 3 (16.7%) was had mild DME, 7 MATERIALS AND METHOD
(38.9%) moderate DME, 8 (44.4%) severe DME. In the Study Design: Analytical Observational Case Control
case group mean duration of DM was 10.7± years and Creatinine level 0.89 mg/dl. Odd ratio for case and con- Study Settings: Department of Endocrinology, Diabe-
trol was calculated by applying Chi-Square test which tes and Metabolic Disease at Hayatabad Medical Com- was 3.86 at 95% of confidence interval (CI) with a P plex Peshawar.
value of 0.0001. (p-value of < 0.05 level of significance). Study Duration: Study duration was 4 months (from
Similarly the Odd ratio for NPDR in case and control 1st September to 30th December 2014). And total data was 3.60 at 95% of CI with a P value of 0.001. Odd ratio collection time was 2 months from first October to 30 for PDR in case and control was 5.14 at 95% of CI with a P value of 0.001. Odd ratio for DME in case and control Sample Size Total of 170 Patients. 84 cases and 84 con-
was 3.04 at 95% of CI with a P value of 0.001.
Anemia was seen in 33 (38.8%) in the case group Inclusion Criteria:
and 12 (11.1%) in the control group. In the case group • Cases: All Type 2 diabetic patients above age 40,
anemia was seen in 11 (32.3%) males and 22 (43.1%) in both male and female, having diabetic retinopa- females. And 3 (21.4%) in mild NPDR, 5 (29.4%) mod- erate NPDR, 8 (66.6%) in severe NPDR, 11 (45.8%) in • Controls: All type 2 diabetic patients with the PDR. In DME anemia was present in 1 (33.3%) mild
same age, sex, demographic location to the case DME, 2 (28.5%) moderate DME, 3(37.5%) severe DME. group, and having no DR were included.
The mean hemoglobin level in patients with PDR was 9.3+0.3, lower than mild to moderate NPDR (10.8+1.3), In both cases and controls the following exclusion cri- 9.7+ 0.2 in Severe NPDR. In DME hemoglobin level Ophthalmology Update Vol. 13. No. 2, April-June 2015 Association of Anemia with Diabetic Retinopathy in Patients with Type II Diabtese Mellitus was 11.1+0.6 in mild DME, 11.0+1.4 in moderate DME, Table- : Anemia and Type of Diabetic Retinopathy
11.2+ 2.1 in severe DM.
Type of Diabetic Retinopathy
Table- : Anemia in Patients with
Diabetic Retinopathy and Normal Retinal Subjects
Diabetic Retinopathy is a major cause of blindness Odd Ratio at 95% of CI=3.8 P value = 0.0001 among the working age group. Because DM and its complications are a public health problem, data on the association of anemia with DR will help in formulating prevention from DM or at least delaying the onset.
In this case control study there was a significant association of anemia with DR in Type 2 DM with odd ratio of 3.86. Anemia was higher in patients with se- vere DR like Severe NPDR and PDR in which anemia was 66.6% and 45.8%. So severity of DR was associated with the severity of anemia. Hb level was also lower in patients having DR 10.3 g/dl, than those with no DR 13.6 g/dl and was much lower in patients with severe NPDR having Hb level of 9.7 g/dl and PDR 9.3 g/dl.
In 2013 Bahar et al. conducted a similar study in Sari, Iran. In their study total 1100 diabetic patients in which 159 subjects with DR (cases) and 318 normal reti- nal subjects (controls). DM patients with anemia were 2.4 times more likely to develop DR. Anemia was ob- Table- : Anemia in Patients
served 45.9% in cases and 26.1% in controls and was 43 with NPDR and Normal Retinal Subjects
% in mild to moderate NPDR, 53% in severe NPDR and PDR. The mean hemoglobin level in controls was high- er (12.73+1.38g/dl) than patients with mild and mod- erate NPDR (12.25+1.38 g/dl) and severe NPDR and PDR (11.89+1.76 g/dl) with a P value of 0.001 respec- tively. Similarly, in our study DM patients with anemia Odd Ratio at 95% of CI = 3.60, P value = 0.001 were 3.8 times more likely to develop DR. Anemia was Table- : Anemia in Patients
38.8% in cases and 11.1% in controls and 21.4% in mild with PDR and Normal Retinal Subjects
NPDR, 29.4% moderate NPDR, 66.6% in severe NPDR, 45.8% in PDR. The mean hemoglobin level in controls was higher (13.6+1.35 g/dl) than patients with mild to moderate NPDR (10.8+1.3g/dl), (9.7+ 0.2g/dl) severe NPDR, and PDR (9.3+0.3g/dl) with a P value of 0.0001 As in the study conducted in Iran, diabetic macu- Odd Ratio at 95% of CI = 5.14, P = 0.001 lopathy (DME) was not included, no association was Table- : Anemia in Patients
found between anemia and DME. While in our study with DME and Normal Retinal Subjects
there was a significant association between anemia and DME with an odd ratio of 3.04. The Hb level was low- er in patients with DME (11.1+2.1g/dl) than controls (13.6+1.35 g/dl). There was no association of treatment of DM like oral hypoglycemia medication and insulin in cases and controls (P value= 0.07). Administration Odd Ratio at 95% of CI= 3.04 P = 0.001 of insulin was higher 7 (8.2%) in cases than controls 6 Ophthalmology Update Vol. 13. No. 2, April-June 2015 Association of Anemia with Diabetic Retinopathy in Patients with Type II Diabtese Mellitus (7.1%) which was similar to the Iran's study in which of 0.001) and anemia was an important finding in di- there was also no association of treatment of DM and abetic patients which was a relevant factor related to insulin was higher (20.5%) in the case group compared the progression of proliferative diabetic retinopathy to the controls (11%).29 (PDR), which can be treated with photocoagulation.31 Qiao et al. in Finland found that the DM patients This study was having similar results to our study in with Hb level lower than 12 g/dl had a two-fold higher which hemoglobin level was also having a significant prevalence of retinopathy after other known factors association with Proliferative DR with an Odd ratio of were controlled. It was also found that in patients with 5.1 at 95% of CI (P value of 0.0001).
retinopathy, the severity correlated with the severity of In a study done in 2012 by JO Chung "Associa- anemia. Among patients who had DR odd ratio of ane- tions between hemoglobin concentration and the clini- mia was 5.3 (95% CI,) for severe DR.32 Similarly in our cal characteristics of patients with Type 2 diabetes" the study it was found that in DM patients anemia was 3.8 patients with lower Hb concentrations had a longer du- times more likely to develop DR and the severity of DR ration of diabetes, a lower body mass index, and lower was correlated with the severity of anemia as odd ratio concentrations of total cholesterol, triglycerides, and for severe retinopathy (PDR) was 5.1 at 95% of CI.
low-density lipoprotein cholesterol. They had a higher David et al. 1997 in Early Treatment of Diabetic prevalence of diabetic retinopathy (DR) and nephropa- Retinopathy Study evaluated a progressive increase thy. The increased prevalence of diabetic retinopathy in risk for high risk PDR with decreasing Hb and sup- was associated with lower Hb concentrations. These porting the importance of anemia as a risk factor for findings suggested that lower Hb concentrations might the progression and severity of DR. The etiology and not only be a consequence of diabetes but may also ac- pathogenesis of anemia in DM patients is multi facto- celerate micro-vascular damage in diabetes mellitus.[36] rial. Decreased erythropoietin production is an impor- While in our study there was no association of dura- tant cause of development of anemia in DM patients. tion of DM with hemoglobin level and patients with a Chronic hyperglycemia is involved in the pathogenesis body mass index (obesity) > 30 kg/m2, LDL > 130mg/ of anemia by means of creating abnormalities in RBCs, dl were excluded in the study. As they were risk fac- oxidative stress, autonomic neuropathy and renal sym- tors for DR so were controlled. Patients with creatinine pathetic denervation. These conditions put the renal < 1.5 mg/dl were included in both cases and controls inerstitium in a hypoxic state and consequently, the proving that anemia in DM patients was unrelated to production of erythropoietin by peritubular fibroblasts anemia due to diabetic nephropathy.
Detection of anemia and its treatment is important A well-accepted cut-point definition of anemia was in the management of diabetic retinopathy. In those selected in our study for our, namely a hemoglobin <13 patients who had both anemia and diabetes mellitus, g/dl in men and <12 g/dl in women. Our results dem- Friedman and associates reported that treatment with onstrated that the presence of anemia is an independ- erythropoietin was correlated with substantial reso- ent risk factor for DR in the case control study. Sub- lution of macular hard exudates. The improved Hb group analysis suggested that the prevalence of anemia concentration with therapy of anemia improves tissue in DR patients (cases) in females was higher (43.1%) oxygenation and may result in reduced VEGF pro- than males (32.3%). A study conducted in 2010 by Ranil duction, which improves the hyper permeability and PK et al. in India in which same definition was used reduces the stimulus for neovascularization.41 These to define anemia, Individuals with anemia were 1.80 observations suggest that anemia evaluation should be times more likely to develop diabetic retinopathy than considered in the routine management of persons with individuals with no anemia. The prevalence of anemia diabetes and should be treated to minimize the risk of was higher in women (26.4%) than in men (10.3%). Men microvascular complications such as nephropathy and with anemia, and not women, had 2 times the risk of developing diabetic retinopathy. While in our study al- though the prevalence of anemia was higher in females, Diabetic retinopathy is emerging a big public but both males and females in cases with anemia were health problem, affecting working age groups. Our 3.8 times more likely to develop DR.30 finding suggests that there was a significant association In a case control study done by Francisco J et al. between anemia and diabetic retinopathy in Type 2 in 2012 there were total 106 T2DM patients in which diabetes mellitus. Anemia was associated with NPDR, Hb was having a significant association with PDR with PDR and DME. So it is concluded that anemia is an inde- odd ratio of 2.43 at 95% of confidence interval (P value pendent risk factor for the development of DR. Severity Ophthalmology Update Vol. 13. No. 2, April-June 2015 Association of Anemia with Diabetic Retinopathy in Patients with Type II Diabtese Mellitus of anemia is co-related with severity of DR. Prevalence 14. Diabetic Retinopathy Guidelines- International Council of of anemia was higher in females than males having Ophthalmology. [online]. 2012 [30/12/2014].
DR., and was also higher in patients with DR who were 15. Available on using both oral hypoglycemic medications and insulin 16. Wu L. Loaiza PF et al.
together. Evaluation and treatment of anemia should be a part of the follow up visits of DM patients. Further 17. Kanski JJ, Bowling B. Clinical Ophthalmology and Systematic studies about the effect of anemia treatment on the se- Approach. Edition 7th. Elsevier limited China: Saunders. 28 April verity of diabetic retinopathy are recommended.
18. Kanski JJ, Bowling B. Synopsis of Clinical Ophthalmology. International Diabetes Federation: The Diabetes Epidemic Is Third edition. Elsevier limited China: 2013; 244-246.
Out of Control [online]. October 20, 2009 [cited 30/12/2014]. 19. Gupta V, Gupta A, Dogra MR, Singh R. DIABETIC RETIN- OPATHY atlas and text. First edition. New delli: 2007; 31-107.
20. ICO Guidelines for Diabetic Eye Care – International Council of Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence Ophthalmology [online]. February 2014 [cited on 30/12/2014].
of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004; 27: 1047–1053. Sivaprasad S, Gupta B, Evans J et al. Prevalence of Diabetic 22. International Clinical Diabetic Retinopathy Disease Severity Retinopathy in Various Ethnic Groups: A Worldwide Perspec- Scale – American Academy Of Ophthalmology [online]. Octo- 2012; 57(4): 347 70.
ber 2002 [cited on 30/12/214]. Available at one.aao.org/asset.
JB Brown, KL Pedula, KH Summers. Diabetic Retinopathy Contemporary Prevalence in a Well-Controlled Population. 23. Thomas MC, MacIsaac RJ, Tsalamandris C, et al. Unrecognized Diabetes Care, 2003; 26: 2637-2942.
anemia in patients with diabetes: a cross-sectional survey. Dia- Thomas, M., Tsalamandris, C et al. Anaemia in Diabetes: An betes Care. 2003; 26(4): 1164-9.
Emerging Complication of Micro vascular Disease. Current 24. WHO - Iron deficiency anaemia: assessment, prevention, and Diabetes Reviews. 2005; 1: 107-126.
control [online]. 2001 [cited 30/12/2014].
Diabetic Retinopathy - Asia Pacific - American Academy of 25. Available at Ophthalmology [online]. November 2013 [cited on 21/9/2014]. 26. Recognizing Anemia in People with Diabetes [online] .March 11, 2009 [cited 24/9/2014].
Vision 2020 – World Health Organization [online]. December 28. Conway BN, Miller RG, Klein R, Orchard TJ. Prediction of Mahar PS, Awan MZ, Manzar N, Memon MS. Prevalence of proliferative diabetic retinopathy with hemoglobin level. Arch Type-II Diabetes Mellitus and Diabetic Retinopathy [online]. 2010 [cited on 30/12/2014]. Available at http://www.atlas.idf.
29. Deray G, Heurtier A, Grimaldi A, Launay Vacher V, Isnard Bagnis C. Anaemia and diabetes. Am J Nephrol. 2004;24:522–6.
Jadoon MZ, Dineen B, et al. Prevalence of blindness and visual 30. Irace C, Scarinci F, Scorcia V, et al. Association among low impairment in Pakistan: the Pakistan national blindness and whole blood viscosity, haematocrit, haemoglobin and diabet- visual impairment survey. Invest Opthalmol Vis Sci. 2006; ic retinopathy in subjects with type 2 diabetes. Br J Ophthal- mol.2011; 95: 94–8.
10. Qayyum AL, Amir Babar AM, Das G. Prevalence of diabetic 31. Maccuish AC. Early detection and screening for diabetic retin- retinopathy in Quetta, Balochistan. Pak J Ophthalmol. 2010;
opathy. Eye. 1993; 7: 254-259.
26(4): 187–192.
32. Congdon NG, Friedman DS, Lietman T. Important causes of 11. Shaikh MA, Gillani S, Yakta D.
visual impairment in the world today. Journal Of The Ameri- can Medical Association. 2003; 290 (15): 2057–2060.
33. Bahar A, Kashi Z, Ahmadzadeh Amiri A et al. Association between diabetic retinopathy and hemoglobin level. Caspian 12. Khan AJ. Prevalence of Diabetic Retinopathy in Pakistan sub- Journal of Internal Medicine.2013; 4(4): 759-762.
jects. A pilot study. J Pak Med Assoc.1991; 41: 49.
34. Rani PK, Raman R, Rachepalli SR. Anemia and Diabetic Retin- 13. Diabetic Statistics in Pakistan [online]. May 8, 2013 [cited opathy in Type 2 Diabetes Mellitus. J Assoc Physicians India. 30/12/2014]. Available at FEBRUARY 2010; 58: 91-4.
35. diabetic microcirculatory disease? Lancet. 1977; 2: 789–91.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Intraocular Pressure Control after
Cataract Extraction with Posterior Chamber Intraocular
Lens Implantation in Phacomorphic Glaucoma
Prof. Laal Mohammad FCPS1, Mohammad Alam FCPS2, Arshad Farzooq FCPS3 Objective: To find out control of intra ocular pressure after cataract extraction with posterior chamber intraocular lens im-
plantation in Phacomorphic glaucoma.
Materials and Methods: This retrospective study was conducted in KDA Teaching Hospital Kohat from January 2009 to
December, 2013 with the objective of finding intraocular pressure control after cataract extraction with posterior chamber intra ocular lens implantation in phacomorphic glaucoma. 48 patients with phacomorphic glaucoma were selected. Informed consent was taken from the patients. Preoperative Intraocular pressure was checked with Perkin Tonometer. All patients were examined with slit lamp. Patients were put on mannitol, systemic carbonic anhydrase inhibitor, and topical antiglau- coma drugs. Topical steroid / antibiotic eye drops were given for five days to one week to control inflammation. After control of IOP and inflammation, patients were operated by conventional extracapsular cataract extraction with posterior chamber Intraocular lens implantation. IOP was checked after one week and one month without anti glaucoma drugs. Total 48 pa- tients comprising of 22(45.83%) male and 26 (54.16%) female were included in the study.
Results: On presentation preoperative intraocular pressure of all the patients was in the range of 31 to 48 mmHg with mean
intraocular pressure of 38.8 mmHg. After surgery no patients was put on antiglaucoma medication. All the patients were put on steroid and antibiotic topical drops for three weeks and systemic pain killer for five days. After one month post operative Intraocular pressure was in the range of 12 – 20 mmHg with mean intraocular pressure of 15.52mm Hg.
Conclusion: There is a significant control of intraocular pressure with normal range in phacomorphic glaucoma after extra-
capsular cataract extraction with posterior chamber intraocular lens implantation.
Key Words: Intraocular pressure, Phacomorphic glaucoma, Extracapsular cataract extraction.
Abbreviations: Intra ocular pressure (IOP), Intra ocular lens(IOL), Extracapsular cataract extraction (ECCE). Posterior
other reasons that the patients avoid treatment.4 Differ- Cataract is considered to be the most significant ent studies have reported that in subcontinent countries cause of blindness globally as well as territorially.1,2 like India, the incidence of intumescent cataract leading Gifford described phacomorphic glaucoma as a sepa- to phacomorphic glaucoma is more in comparison to rate entity for the first time in 1900.3 He attributed it western world.5 Cataract extraction is the only treat- to hypermature cataract. In phacomorphic glaucoma, ment of phacomorphic glaucoma. But before surgery the lens blocks the forward flow of aqueous humor IOP is being lowered down to a safe level with medica- through the pupil resulting in rise of IOP. This classi- tion to prevent glaucoma related problems. This study cally occurs in large intumescent cataract which is then was done to find out the IOP control after cataract ex- named as phacomorphic glaucoma. This lens induced traction with PC- IOL.
glaucoma is a preventable and a treatable disease if MATERIALS AND METHODS
managed at proper time. This condition still exists in This retrospective study was conducted in KDA the world. Phacomorphic glaucoma is due to lack of Teaching Hospital Kohat from January 2009 to Decem- awareness of cataract and delayed surgical interven- ber 2013 with the objective to find out IOP control after tional removal. It is normally due to wrong concept cataract extraction with PC-IOL in patients of phaco- that cataract should be mature at the time of surgery, morphic glaucoma. Diagnosis of phacomorphic was lack of need for better vision, concurrent systemic dis- made when patients presented with symptoms of pain, eases , old age, ignorance and economic constraints are redness of involved eyes, headache and above normal IOP, shallow anterior chamber and intumescent cata- 1Prof. of Ophthalmology, 2Associate Prof. of Ophthalmology, 3Oph- ract. Proper proforma was designed for documenta- thalmologist, KMU Institute of Medical Sciences, Kohat tion of clinical findings of patients, time and duration of Correspondence: Professor Lal Mohammad Department of Ophthal- presentation on arrival. IOP was checked with Perkin's mology, KMU Institute Of Medical Sciences, K.D.A Kohat Tonometer and visual acuity was recorded. Total 48 patients were selected out of which 22 (45.83%) were Received: January 2015 Accepted: February 2015 male and 26 (54.16%) were female. (Table-I) Age was Ophthalmology Update Vol. 13. No. 2, April-June 2015 Intraocular Pressure Control after Cataract Extraction with Posterior Chamber Intraocular Lens Implantation in Phacomorphic Glaucoma ranging from 59 years to 73 years with mean age of 66.3 down to postoperative mean IOP 15.52 mmHg. There years. Duration of the symptoms were recorded. (Ta- are many national and international studies showing similar results. Mandal AK,Gothwal UK have reported All the patients IOP were controlled with man- IOP control in normal level in all patients operated for nitol, systemic carbonic anhydrase inhibitor and topi- phacomorphic glaucoma.6 Rajal AP, Karki DB report- cal antiglaucoma medicine. Steroid/antibiotic topical ed IOP control after cataract surgery in phacomorphic drops were also given to the patients to control inflam- glaucoma to be from 14 – 22 mmHg in all patients. In mation for 5-7 days preoperatively. All the patients their study female patients were more than male as in were operated by conventional extra capsular cataract our study.7 Payal Gupta study demonstrates post op- extraction with PC- IOL implantation. Those patients erative IOP to be lower than 20 mmHg in all phaco- with preoperative visual acuity of no perception of morophic glaucoma patients without postoperative light were excluded from the study. After surgery pa-
antiglaucoma medicine.8 Sing G and Vankatesh et al tients were put on steroid/antibiotic topical drops for studies also reported post operative IOP control of 20 three weeks and pain killer for 5 days. No antiglauco- mmHg or less in all patients.9,10 Mohinder Singh, Has- ma medications were prescribed postoperatively. IOP san Al Arrayyed studies reveal IOP control of below 21 was checked after one week and one month.
mmHg in all patients like in our study. However, the age of patients with phacomorphic glaucoma were dif- On presentation, preoperative IOP of all patients was in range of 31 mmHg to 48 mmHg with mean IOP R Ramekrishanan, Davendra Maheshwari et al of 38.8 mmHg. Post operative IOP after one week was conducted a study of IOP control in phacomorophic in range of 12 to 22 mmHg with mean IOP of 15.91 glaucoma in 74 patients. Postoperative IOP was con- mmHg. After one month post operative IOP was in the trol and below 20 mmHg in all patients with out an- range of 12-20 mmHg with mean IOP of 15.52 mmHg.
tiglaucoma therapy.12 They used sutureless surgery technique so it is clear that IOP control in phacomor- phic glaucoma does not depend upon the method used. Table-I: Showing gender distribution.
Nithisha TM, Mallikarjun, Salagar reported that 28% of No of Patients
phacomorophic glaucoma patients had postoperative IOP of more than 20 mmHg which is contradictory to our study. Probably this variation may be due opera- tion complication.13 PS Mazhar, M Amin Shahzad have Table-II: Duration of presentation
reported in their study 3.6% of all glaucoma was phaco- No of patients
morphic needed urgent control of IOP and removal of lens.14 This ratio is less as compared to other study.
Phacomorphic Glaucoma is a devastating ocular condition with high IOP. If treated early with cata- Table-III: Preoperative and postoprtative IOP
ract extraction and implantation of PC-IOL, pupillary Range in mmHg
Mean in mmHg
block will be removed and there is significant fall in IOP within normal range. The patients do not need an- tiglaucoma therapy post operatively. Therefore public Postoperative One week awareness programs may be carried out through print Postoperative One month and electronic media and public gatherings to get rid of this problem.
Intumescent cataract is the main cause of pupil- Thulasiraj RD, Rahamathulla R, Saraswati A, Selvaraj S, Ell- lary block phacomorphic glaucoma resulting in high wein LB. The Sivaganga eye survey: I. Blindness and cataract IOP with damage to the Optic nerve. After control of surgery. Ophthalmic Epidemiol. 2002;9:299-312. preoperative IOP the patients are operated for cataract Thylefors B, Negrel AD, Pararajasegaram R, Dadzie KY. Global data on blindness. Bull World Health Organ.1995;73;115-21. extraction, the obstruction to the out flow of aquous Duke-Eder S. System of Ophthalmology. Vol. XI: Diseases of humor is removed and there is drastic fall in IOP and the lens and Vitreous; Glaucoma and Hypotony. St. Louis: CV the patients do not need any antiglaucoma therapy. Mosby 1969; 662-3.
Tomey KF, al-Rajhi AA. Neodymium: YAG laser iridotomy in The same statement is true as observed in our study the initial management of phacomorphic glaucoma. Ophthal- in which preoperative mean IOP 38.8 mmHg dropped mology. 1992;99:660-5. Ophthalmology Update Vol. 13. No. 2, April-June 2015 Intraocular Pressure Control after Cataract Extraction with Posterior Chamber Intraocular Lens Implantation in Phacomorphic Glaucoma Lowe RF. Angle closure glaucoma and cataract East. Arch Oph- cacy of manual small incision cataract surgery for phacolytic thalmol. 1973;! :80-3.
glaucoma. Br J Ophthalmol 2007; 91 (3): 269-70.
Mandal AK, Gothwal VK. Intraocular pressure control and 11. Singh M, Al-Arrayyed H, Krishnan R. Intraocular Lens Im- visual outcome in patients with phacolytic glaucoma managed plantation in Phacomorphic Glaucoma.Bahrain Medical Bulle- by extracapsular cataract extraction with or without posterior tin Vol 24,NO 3 Sep 2002.
chamber intraocular lens implantation.Ophthalmic Surg La- 12. Ramakrishanan R, Maheshwari D, Kader MA, Singh R, Pa- war N, and Bharathi MJ. Visual prognosis, intraocular pressure Rijal AP, Karki DB l. Visual outcome and IOP control after cata- control and complications in phacomorphic glaucoma follow- ract surgery in lens induced glaucoma. Kathmandu University ing manual small incision cataract surgery. Indian J Ophthal- Medical Journal(2006)Vol,4,No1, Issue 13,30-33.
mol. 2010 Jul-Aug; 58(4): 303-306. Gupta P, Bhagotra S, Prakash S. Pattern and Visual Outcome in 13. Nithisha TM, Salagar M, Hiremath LD, Selvan VT, Hiremath Lens Induced Glaucoma.JK Science Vol 14 No 4 Oct-Dec 2012.
DA. A non randomized clinical study of posterior chamber IOL Singh G, Kaur J, Mall S. Phacolytic glaucoma-Its treatment by implantation in lens induced glaucoma. Medica Innovatica, planned ECCE with PC IOL implantation. Ind J Ophthalmol Dec 2014,Vol 3(2).
1994; 42:145-47.
14. Mahar PS, Shahzad MA. Glaucoma Burden in a Public Sector 10. VenkateshR, TanCS, Kumar TT, Ravindran Rd. Safety & effi- Hospital. Pak J Ophthalmol 2008, Vol 24 No. 3 65-year-old man presented Bilateral painless swelling of the lower eyelids bilaterally since 2-months. On Examination bilateral palpebral edema and palpable masses were identified CT Scan showed enlargement of both lower eyelids with no associated cervical lymphadenopathy. Excision biopsy of the palpebral tumor revealed mucosa-associated lymphoid tissue (MALT) lymphoma.
Comprehensive physical examination revealed no other lesions. Localized MALT lymphoma of the lower eyelids was diagnosed. The patient was treated with radiation therapy had a complete response. After 18 months of follow-up, ophthalmologic examination and CT revealed no relapse of lymphoma at a local or a distant site.
Issam Lalya, M.D. Hamid Mansouri, Ph.D., Military Teaching Hospital Mohammed VRabat, Morocco., Curtesy NEJM issamlalya@yahoo.fr Ophthalmology Update Vol. 13. No. 2, April-June 2015 Causes of Low vision and Quality of Life after
Rehabilitation in Children & Adults
Mohammad Kashif BVS, MPH1, Mohammad Arshad Raza FCPS2 Siraj Safi BVS, DBO3, Fahim Marwat BVS4, Samiuddin BVS5 ABSTRACT
Objectives
1. To determine the and causes of low vision in adult and children.
2. To evaluate quality of life before and after using low vision devices
Materials & Methods: This Cross-sectional study conducted at Low Vision Clinic, Department of Ophthalmology Hayat-
abad Medical Complex during a period of six month from June 2014 to Dec 2014. A total of one hundred and sixty five sub- jects were assessed and referred by Ophthalmologist. The magnitude of etiology for low vision were recorded and analyzed. The patients having best corrected visual acuity < 6/18 in the better eye were consulted for low vision re-assessment with the help of LVDs. Quality of life questionnaire (LVQOL) was administered to every patient on first and follow up visit after
using LVDs in order to determine the impact of LVDs on quality of life of the selected subjects. Data was analyzed with SPSS 16. Frequencies of responses to different questions were calculated.
Results: Total of one hindered and sixty five patients were include in study having adults were 102 (61.8%), Children
63 (38.18%).The main causes of low vision in children includes stargardt's disease 22.2%, nystagmus 17.4%, Retinitis pigmentosa 14.28% albinism with nystagmus 12.69%, Aphakia 12.69%, Myopia 11.1%, Cong. Cataract 3.17%, corne- al opacity 3.17%, cone dystrophy 1.59%. Among adult group the main causes were age related macular degeneration 21.50%, corneal opacity 15.68%,Retinitis pigmentosa 13.72%, aphakia%, high myopia 8.82%, congenital cataract 5.58%, glucoma5.88%,nystagmus 4.70%, oculo-cutaneous albinism 3.92%, Stargadt,s maculopathy 3.92%, cone dystrophy 3.92%. After using low vision devices the population with group of great problem reduced to only 10% while the moderate category reduced to 20% respectively. Similarly the problem with activities of daily living reduced after using LVD,s from 65% to 35% so the reduction was almost half and those who were having no problem increased from 13% to 49 %. Although the score of the population in the psychological adjustments was less as compare to other aspect e.g. reading, distance equity etc but still significant amount of population gain a reasonable score after using LVD,s.
Conclusion : Efforts should be done to reduce the low vision burden of the diseases which are treatable, . Visually impaired
patients due to different etiologies do benefit from low vision services which facilitate vision having dramatic impact on the quality of life of those suffering subjects.
Key Words: Visual impairment, Low vision devices, quality of life
vision is characterized by irreversible visual loss and a Low Vision: a person with low vision is one who
reduced ability to perform many daily activities, It is has impairment of visual functioning even after treat- an important public health problem and provision of ment and/or standard refractive correction, and has a low vision services is one of the priorities in the global visual acuity of less than 6/18 to light perception, or a initiative, VISION 2020—The Right to Sight.
visual field less than 10 degrees from the point of fixa- Low Vision and Quality of Life: The quality of life of
tion, but who uses, or is potentially able to use, vision a person with low vision is always compromised. The for the planning and/or execution of a task for which presence of low vision affects functional and social life vision is essential.1 Or Low vision is visual acuity less of an individual and has a negative effect on physical than 6/18 and equal to or better than 3/60 in the bet- and emotional well being and increased emotional dis- ter eye with best correction.1 (WHO)" Functionally, low tress.2 The provision of low vision services and use of low vision devices allows people with visual 1Senior Optometrist, Pakistan Institute of Community Ophthalmol- impairment to use their limited residual vision as opti- ogy Hayatabad Medical Complex, Peshawar. 2Eye Specialist, Dis- trict Head Quarter Hospital, Nowshera, KPK. 3Lecturer Optometry, mally as possible. Pakistan Institute of Community Ophthalmology Hayatabad Medical 1.3 ICD-10 Classification of Visual Impairment: "The
Complex. 4Orthoptist, Pakistan Institute of Community, Ophthalmol- ogy Hayatabad Medical Complex. 5Optometrist, Pakistan Institute of
world Health Organization ICD-10 (International Clas- Community, Ophthalmology Hayatabad Medical Complex peshawar.
sification of Diseases) categories the visual impairment in to three categories 1: Moderate visual impairment Correspondence: Mohammad Kashif MPH, Senior Optometrist-Fac- ulty Member, Pakistan Institute of Community Ophthalmology Hayat- from all causes visual acuity of 6/18 to 6/60. 2: Severe visual impairment from all causes 6/60 to 3/60 in the better eye and 3: Blindness from all causes 3/60 in the Received: December 2014 Accepted: February 2015 Ophthalmology Update Vol. 13. No. 2, April-June 2015 Causes of Low vision and Quality of Life after Rehabilitation in Children & Adults 1.5 Causes of Low Vision: Globally the principal causes
naire was administered to every patient on first visit of visual impairment are un-corrected refractive errors and after using LVDs.
and cataracts, 43% and 33% respectively. Other causes 1.6 Data Management and Analysis: Data were entered
are glaucoma, 2%, age related macular degeneration in the register after each low vision day and then en- (ARMD), diabetic retinopathy, trachoma and corneal tered and analyzed using SPSS version 20. Frequency opacity. A large proportion of causes, 18%, is undeter- tables and cross tables were used. mined. The causes of blindness are cataract, 51%, glau- coma, 8%, AMD, 5%, childhood blindness and corneal The study population was divided in to two groups on opacities, 4%, uncorrected refractive errors and tracho- the basis of age.
ma, 3%, and diabetic retinopathy 1%, he undetermined 1: Adults
causes are 21%.9(WHO 2010) Table-1: Age + Gender wise distribution of study population
Global causes of visual
impairment inclusive of blindness, as percentage
Gender wise Distribution of study population
This study conducted at low vision clinic in De- partment of Ophthalmology Hayatabad Medical Com- plex Peshawar, Pakistan. The study sample of 165 patients were thoroughly assessed / examined and treated by Ophthalmologist. Those patients who did Table-2: Distribution of causes of low
not achieved visual acuity better than 6/18 after surgi- vision among total population
cal, medical or optical treatment were referred to low vision clinic. The other sources of referral are patients of Patients
referred by ophthalmologist from Tehsil and District Retinitis Pigmentosa head quarter hospitals from all over the province.
Low Vision assessment: The patients were seen first by
Age Related Macular ophthalmologists and then referred to low vision clinic for assessment, where they are refracted and assessed for LVDs Optometric examination included detailed Stargardts Disease history of the patient, his/ her family history; function- al, occupational and clinical assessment. The anterior and posterior segment examination was performed. The diagnosis was confirmed by at least one ophthal- mologist and one optometrist. Oculo-cutaneous Albinism Visual Acuity: Distance visual acuity was measured by
with Nystagmus.
Log MAR chart, near visual acuity was measured Wil- liam Feinbloom and Lea Cards. The distance between the near acuity chart and the patient was recorded for calculation of magnification.
Quality of life questionnaire: The LVQOL question-
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Causes of Low vision and Quality of Life after Rehabilitation in Children & Adults Table-3: Distribution of causes of low vision among Children
Table-6: Categories of Low Vision in Children
of Children Percentage
Type of Low Vision
of Patients Percentage
Stargardts Disease Moderate visual Impairment Severe Visual Impairment Retinitis Pigmentosa Blind or profound Visual Oculo-cutaneous Albinism with Nystagmus.
Table-7: Categories of Low Vision in Adult population
Type of Low Vision
Congenital Cataract of Patients
Moderate visual Impairment Severe Visual Impairment Congenital Glaucoma Blind or profound Visual Table: 8 Distributions of Low
Table: 4 Distribution of causes
Vision Device among the total study population
of low vision among Adult population
S. No Type of devices children
of Children Percentage
11(17.4%) 43(42.15%) 54(32.7%) Age Related Macular 16(15.6%) 26(15.75%) Corneal Opacities Retinitis Pigmentosa Table-9: Problems during Distance Vision, Mobility
and Lighting among Total Study population before and
after Low Vision Aids
Congenital Cataract S.No Categories Number Percentage Number Percentage
Oculocutaneous Albinism Stargardts Maculopathy Categories of Low Vision in study Population: The
A group of diseases in either ages and genders World Health Organization Classify the low vision in that leads to low vision, affects the overall quality of to three broad categories on the basis of the best cor- life and has profound physical, psychological and so- rected vision.1: Moderate (6/60 < VA < 6/18, 10° < VF cial impacts. Our study investigates the major causes < 20°) 2: severe vision impairment (3/60 < VA < 6/60, of low vision in both children and adult population, 5° < VF < 10°) 3: Blindness or profound vision impair- while most of the studies conducted are only confined ment (VA < 3/60, VF < 5°).
to either adults or children. More over the quality of Table-5: Categories of low vision in Total population
life score is measured that shows the affectivity of low vision services that consequently helps in planning and Type of Low Vision
of Patients
development of low vision services. If we look at the re- sults the retinal diseases were commonest among both adults and children. In retinal diseases the pattern of diseases was different in two groups. Stargardts macu- lopathy in which the onset takes place in the first dec- Blind or profound Visual ade of life and is almost untreatable, so it runs through- out the life. The child and/or parents usually noticed Ophthalmology Update Vol. 13. No. 2, April-June 2015 Causes of Low vision and Quality of Life after Rehabilitation in Children & Adults the decrease of vision when the child is admitted in the pass almost all the aspects of quality of life in terms of school. Nystagmus is the second leading cause among vision. The results of the study revealed that in total children that accounts for about 17%, Retinitis pigmen- population 68% of the population had great problem, tosa 14% and oculo-coetaneous albinism with nystag- 27% had moderate problem while 5% had no problem mus 8%. If we add the nystagmus without albinisim with distance vision mobility and lighting before low and with albinism it becomes 25% and becomes the devices. After using low vision devices the population leading cause of low vision in children. The severity of with great problem reduces to only 10% while the mod- the low vision caused by nystagmus is comparatively erate category reduced to 20% respectively. Similarly lower than retinitis pigmentosa and stargardts disease. the problem with activities of daily living reduced after Retinitis pigmentosa was prevalent in both adult and using LVD,s from 65% to 35% so the reduction was al- children but more in adults than in children. The reason most half and those who were having no problem in- may be that R/P is a progressive disease and some pa- creased from 13% to 49 %. Although the Score of the tients do not noticed the deterioration of vision in early population in the psychological adjustments was less life until it goes on progression and causes much dam- as compare to other aspect eg reading, distance equity age to the vision which is then noticed by the patients. etc but still significant amount of population gain a In the case of adults the major cause of low vi- reasonable score after using LVD,s. In general, optical sion observed was age related macular degeneration devices (including distance or near magnifiers, field (ARMD) which is the disease of old population and expanders, night-vision aids) are less useful for those caused by degenerative changes in the retina with with poorer levels of visual function, and those affected growing age. Its onset takes place after fourth decade require environmental modification (e.g., light aug- of life. ARMD badly affects the central vision and. Illu- mentation, improving mobility). Evidence exists that minated magnifiers enhance the reading capabilities of low-vision services improve quality of life and mental the patients and can improve quality of life by helping state clinical trial evidence of the effectiveness of spe- in reading, signing cheques, reading price tags in the cific interventions for individuals with FLV is lacking. market, needle threading and reading holly Quran. A recent Cochrane review concluded that further The second leading cause of low vision among research is recommended to compare different types of adult population was corneal opacities 16% R/P and low-vision devices as well as to delineate patient char- aphakia 13 and 12% respectively. High myopia was re- acteristics that predict performance. Designing clinical sponsible for about 8% in adults. These results are co- trials of low-vision interventions is challenging due inciding with the results of the study conducted in the to the heterogeneous nature of the causes and conse- same center but the target population was only adults. quences of the conditions causing FLV, the wide range The study shows that the main causes of visual impair- of possible interventions, the fact that interventions ment included nystagmus (15%), Stargardt's disease must be tailored to individuals' needs, and the large (14%), maculopathies (13%), myopic macular degenera- number of possible outcomes research of this kind is tion (11%) and oculocutaneous albinism (7%). The per- urgently needed in developing counties, as findings centages of visually impaired, severe visually impaired from studies in industrialized countries may not apply and blind were 33.8%, 27.2% and 39.0% respectively. in situations in which the causes and functional visual A study conducted on the causes of low vision in Mo- needs are quite different.
himbili National Hospital Dar us Salaam Tanzania re- CONCLUSION & RECOMMENDATIONS
vealed that among 561 patients, there were 100(17.83%) Efforts should be done to reduce the low vision patients with low vision. The highest proportion (10.3) burden of the diseases which are treatable, genetic of low vision patients was found among the age group counseling of the families having disease like Retini- of 18-27 years age, and a gradual trend of decrease in tis pigmentosa to minimize its occurrence by avoiding low vision patients with increasing age (0.2% in eldest consanguine marriages. Visually impaired children es- age group of 78-87 years) was observed. Optic neuropa- pecially with hereditary/congenital ocular anomalies thy was the predominant cause of low vision (47%) in benefit from refraction and low vision services which the study population, followed by ARMD (9%), Reti- facilitate vision enhancement and inclusive education. nitis pigmentosa (7%), glaucoma (7%), albinism (7%), Awareness among eye care professionals should be en- amblyopia (7%), corneal diseases (5%), refractive errors hanced, in order to facilitate referral and management (4%), diabetic retinopathy (4%) and macular scars (3%).
of low vision. Efforts to expand low vision services in- The severity of the problem was categorized in to cluding making simple, high quality, low cost, Low Vi- severe, moderate and none. These questions encom- Ophthalmology Update Vol. 13. No. 2, April-June 2015 Causes of Low vision and Quality of Life after Rehabilitation in Children & Adults THE LOW VISION QUALITY-OF-LIFE QUESTIONNAIRE (LVQOL)
Distance Vision, Mobility and Lighting
How much of a problem do you have:
With your vision in general With your eyes getting tired (e.g only being able to do a task for a short period of time) With your vision at night inside the house Getting the right amount of light to be able to see With glare (e.g dazzled by car lights or the sun) Seeing street signs Seeing the television (appreciating the pictures) Seeing moving objects (e.g. cars on the road) With judging the depth or distance of items (e.g. reac hing Seeing steps or curbs Getting around outdoors (e.g. on uneven pavements) because of your vision Crossing a road with traffic because of your vision Adjustment
Because of your vision, are you:

Unhappy at your situation in life Frustrated at not being able to do certain tasks Restricted in visiting friends or family Poorly Not explained
How well has your eye condition been explained to you Reading and Fine Work
With your reading aids / glasses, if used, how

much of a problem do you have:
Reading large print (e.g. newspaper headlines) Reading newspaper text and books Reading labels (e.g. on medicine bottles) Reading your letters and mail Having problems using tools (e.g. threading a needle or Activities of Daily Living
With your reading aids / glasses, if used, how

much of a problem do you have:
Finding out the time for yourself Writing (e.g. cheques or cards) Reading your own hand writing With your every day activities (e.g. house-hold chores) Ophthalmology Update Vol. 13. No. 2, April-June 2015 Causes of Low vision and Quality of Life after Rehabilitation in Children & Adults Annexure I: Data Collection Instrument
SERIAL NO:
Ophthalmology Findings Cause of Low Vision /Blindness Distance Visual Acuity (Without Glasses) Distance Visual Acuity Near Visual Acuity Low Vision Assessment Type of Telescope Type of Magnifier Visual Acuity With LVD World Health Organization /International Agency for the Pre- 5. World Health Organization/Global Data on Visual impair- vention of Blindness. State of the World's Sight Vision 2020: The Right to Sight 1999–2005. Geneva, Switzerland: WHO; 6. Pararajasegaram R. VISION 2020 - The Right to Sight: from strategies to action (editorial). Am J Ophthalmol. 1999; 128: 359- Scott IU, Smiddy WE, Schiffman J, Feuer WJ, Pappas CJ. Qual- ity of life of low-vision patients and the impact of low-vision Resnikoff S. Pacolini D. Etya'ale D, et al. Global data on visual services. Am J Ophthalmol. 1999;128:54---62.
impairment in the year 2002. Bull World Health Organ. 2004; 3. World Health Organization. ICD-10 International Statistical Classification of Diseases and Related Health Problems, 10th Pollard.T, Simpson.J,Lamoureux.E and Keeffe.J. Barriers to ac- Revision In: Johnson GJ, Minassian DC, Weale R, Eds. The Epi- cessing low vision services. Ophthal Physio Opt 2003;23: 321- demiology of Eye Disease. London: Chapman & Hall Medical; 9. World Health Organization/Global Data on Visual impair- Dineen B, Bourne RR, Jadoon Z, et al. Causes of blindness and visual impairment in Pakistan. The Pakistan national Blindness 10. mshah et al causes of low vision in children.
andVisual Impairment Survey.Br J Ophthalmol.2007; 01:1005– 11. World Health Organization. Consultation on Development of Ophthalmology Update Vol. 13. No. 2, April-June 2015 Causes of Low vision and Quality of Life after Rehabilitation in Children & Adults Standards for Characterization of Visual Loss and Visual Function- Ophthalmol 2003;87:820–828. ing. 2003; WHO Geneva, Switzerland. PBL/03.91 16. YemaneBernahe et al. prevalence and causes of blindness and 12. ‐ Resnikoff S, Pascolini D, Etya'ale D, et al. Global data on visual low vision in Ethiopia, Ethiop. J. Health Dev. 2007; 21(3).
impairment in the year 2002. Bull World Health Organ 17. Keeffe J. Vision Assessment and Prescription of Low Vision De- 13. World Bank. World Bank list of economies vices. J Comm Eye Health 2004;17: 3-4.
18. Best AB. The management of low vision in Children. Br J Oph- thalmol. 1995;13: 65-68. 14. ‐Organisa on for Economic Co‐opera on and Develop‐ ment. 19. Hornby SJ, Adolph S, Gothwal VK, et al. Evaluation of children Policy Briefs available at in six blind schools of Andhra Pradesh. Indian J Ophthalmol. 2000;48: 195-200. 15. Dineen, Bourne, Ali, et al, Prevalence and causes of blindness 20. Rahi JS, Sripathi S, Gilbert CE, et al. The importance of prenatal and visual impairment in Bangladeshi adults: results of the Na- factors in childhood blindness in India. Dev Med Child Neurol. tional Blindness and Low Vision Survey of Bangladesh. Br J 1997;39 : 449-55.
18th Annual Islamabad
Congress of Ophthalmology
at Bhurban (Murree) from Please Contact: Dr. Waheed Afzal, President OSP Federal Secretariat Phone: 03335153266 Ophthalmology Update Vol. 13. No. 2, April-June 2015 The Efficacy of Limbal Based Conjunctival
Flap in Patients Undergoing Trabeculectomy
with Intra-operative Mitomycin C
Hasan Yaqoob FCPS, FRCS1, Mohammad Idris FCPS2 Zubairullah Khan FCPS3, Zubairullah Khan FCPS4, Mudasser Hussain Turi FCPS5 Naseer Ahmad DOMS5, Bilqees Hassan MBBS6 Objective: To determine the efficacy of limbus based conjunctival flap in patients undergoing trabeculectomy with intraop-
erative Mitomycin C.
Design: interventional case series
Setting: Department of Ophthalmology, Khyber Institute of Ophthalmic Medical Sciences (KIOMS), Post Graduate Medical
Institute, Lady Reading Hospital, Peshawar.
Duration: 18 months, from 1st January2012 to30th June 2013.
Subjects: Eighty eyes of 80 patients diagnosed as having glaucoma.
Main outcome measure:
1. Intraocular pressure, effective rate of fornix based trabeculectomy with mitomycin C and limbal based trabeculectomy
with mitomycin C in lowering intraocular pressure.
2. Bleb formation
Results: 80 eyes underwent limbal based trabeculectomy with MMC. 56.3% of patients were male and 43.8% were female.
The mean age was 54.1 years. Preoperative visual acuity ranges from 6/6 to counting fingers (CF). The mean intraocular pressure at the end of follow-up was 12.12 mmHg with standard deviation + 0.68 in group 2. IOP >21 mmHg was not found in any patient. The effective rate of limbal based trabeculectomy with MMC was 85% in formation of bleb on 1st postopera- tive day .
Conclusion: limbal based trabeculectomy with intraoperative MMC is an alternative and effective method in glaucoma
treatment surgically.
Key Words: Glaucoma, Trabeculectomy; intraocular pressure, Mitomycin C.
order alters aqueous outflow. Secondary glaucoma may Glaucoma is characterized by progressive loss of be acquired or developmental and of the open-angle or retinal ganglion cells leading to characteristic visual angle-closure type.
fields defects and optic nerve head cupping and pal- Secondary open-angle glaucoma may be:
lor1. It is an optic neuropathy secondary to various risk 1. Pre-trabecular like neovascular glaucoma.
factors including increased IOP.
2. Trabecular like pigmentary glaucomas, red cell Glaucoma may be (a) congenital or (b) acquired. glaucomas, ghost cell glaucomas, phacolytic glau- Further sub-classification into open-angle and angle- comas, pseudoexfoliative glaucomas and post- closure type is based on the mechanism by which aque- traumatic angle recessive glaucoma etc.
ous outflow is impaired. The glaucoma may also be (a) 3. Post-trabecular in which aqueous outflow is im- primary or (b) secondary depending on the presence or paired by elevated episcleral venous pressure due absence of associated risk factors. In primary glaucoma to carotid-cavernous fistula, Sturge-Weber syn- there is no associated ocular disorder while in second- drome and obstruction of superior vena cava.
ary glaucoma a recognizable ocular or non-ocular dis- Secondary angle-closure glaucoma may be due to posterior forces which push the peripheral iris against 1Consultant, Ophthalmology Unit, North West General Hospital, the trabeculum (iris bombe due to seclusion-pupillae) Peshawar, KPK. 2Medical Officer, Ophthalmology UNIT, PGMI, LRH Peshawar. 3Consultant, Ophthalmology, Mission Hospital, Peshawar, or anterior forces which pull the iris over the trabecu- KPK. 4Associate Ophthalmologist, LRBT Free Eye Hospital, Mandra, lum by contraction of inflammatory or fibrovascular Rawalpindi. 5Trainee Medical Officer, Hayatabad Medical Complex, Peshawar. 6Medical Officer Pakistan Institute of Ophthalmology,PICO, membrane (e.g. late neovascular glaucoma).
Patients present with a variety of signs and symp- Correspondence: Dr. Hasan Yaqoob FCPS, FRCS Consultant, toms like pain, watering, dimness of vision, headache, Ophthalmology UNIT, North West General Hospital, Phase V, nausea and vomiting depending on the nature of glau- Hayatabad, Peshawar, KPK. Pakistan. Cell: 00992-0345-2565959, coma. Therefore, slit-lamp biomicroscopy, fundoscopy, tonometry, gonioscopy and perimetry is mandatory for Received: December 2014 Accepted: January 2015 management of these patients to see for ciliary injec- Ophthalmology Update Vol. 13. No. 2, April-June 2015 The Efficacy of Limbal Based ConjunctivalFlap in Patients ndergoing Trabeculectomy with Intra-operative Mitomycin C tion and corneal oedema, optic disc cupping, intraoc- gery or trauma.Patients with congenital or normal ular pressure, angle details and visual field defects. tension glaucoma. Patients with secondary glau- Glaucoma is a highly prevalent and vision threatening coma like uveitic, neovascular or pseudophakic condition affecting approximately 66 million people Study design: prospective, interventional case series.
worldwide.2 In a recent study conducted in Pakistan, Data collection procedure: The study was conducted
it was showed that glaucoma accounted for 8.1% of all at Out Patient Department, Eye Unit of Lady Reading eye admissions. Open-angle glaucoma was responsible Hospital, Peshawar. Before we start the study, permis- for 37.6% or 731 glaucoma admissions followed by sec- sion from the hospital ethical committee was obtained. ondary glaucoma (35.0%) and angle-closure glaucoma An informed written consent was obtained from the patient. The patients were evaluated for inclusion and In our set-up, people present with advance disease exclusion criteria. Patients for trabeculectomy will be due to poverty, illiteracy and lack of district-based eye admitted to eye unit of Lady Reading Hospital, Pesha- care. Different types of treatment options are available war, through an eye OPD waiting list. A detailed histo- like anti-glaucoma drugs, laser treatment and surgi- ry regarding dimness of vision (DV) (whether sudden cal interventions. Treatment of choice in our setting is or gradual, painless or painful), previous ocular trauma surgical intervention due to poverty, poor drug com- and intraocular surgery will be taken. Pre-op ocular ex- pliance, late presentation and high failure rate of laser amination including best corrected visual acuity, rela- trabeculoplasty.4 Trabeculectomy alone introduced by tive afferent papillary defect( RAPD) and slit lamp ex- Cainrs in 1968 and modified by Watson in 1970,5, 6 or amination of optic disc with 90 D lens noting optic disc with antimetabolite (Mitomycin-C, 5-Fluoro-urocil) has cupping and cup-disc ratio( c/d ratio), gonioscopic ex- been the surgical method of choice.7 ,8 9 amination of angle structure by Goldmann single mir- Objective; To determine the efficacy of Limbus based
ror goniolens, intraocular pressure measurement(IOP) conjunctival flap in patients undergoing trabeculecto- by Goldmann applanation tonometer and visual field my with intraoperative Mitomycin C.
testing using Humphery perimeter. Laboratory investi- Efficacy: it will be measured on the basis of conjuncti-
gations like Hb %, HBA1C, Ag, anti-HCV, blood sugar val bleb formation and normal intraocular pressure (11- etc will be done in Pathology Department, Lady Read- 21mmHg) and thus affectivity of the procedure will be ing Hospital, Peshawar. Radiological investigations like chest X-Ray will be done in Radiology Department, MATERIAL AND METHODS
Lady Reading Hospital, Peshawar. The surgery will Setting: Department of Ophthalmology, Khyber Insti-
be done both under local and general anesthesia. On tute of Ophthalmic Medical Sciences (KIOMS), Post first day after surgery and on follow up the patients Graduate Medical Institute, Lady Reading Hospital, will be assessed for visual acuity, conjunctival bleb, and intraocular pressure. Patients will be examined on Duration of Study: 18 months, from 1st January2012 to
first post-op day and will be discharged after being fol- 30th June 2013.
lowed up on 10th postoperative day and 1 month. Nom- Sample Size: Using WHO sample size calculator, where
inal data of the outcome of surgery for all the patients Confidence level=95, will be recorded on a data collection proforma on each Absolute precision=0.03, follow up visit.
Population proportion (P) =10%.
Surgical Procedure: Limbal based trabeculectomy was
The sample size=80 Sampling Technique: non probability: consecutive
Data analysis procedure: After completion of data col-
lection, the data will be analyzed using SPSS version a. Inclusion criteria;
13.0. All categorical variables including gender and i. patients of 30 to 60 years, both male and female.
operative outcome will be given in frequencies and ii. Patients of primary open angle glaucoma,angle percentages; mean and standard deviation will be cal- closure glaucoma pseudoexfoliative glaucoma culated for numerical variables for example age and and induced glaucoma with raised intra ocular intraocular pressure on day 1, 10, and 30. Operative pressure not controlled by maximum treatment or outcome in the form of intraocular pressure and bleb poor compliance.
formation was documented and presented in the form b. Exclusion criteria;
Patients with previously failed trabeculectomy. Patients with history of previous intra ocular sur- Eighty patients were diagnosed as "Glaucoma" Ophthalmology Update Vol. 13. No. 2, April-June 2015 The Efficacy of Limbal Based ConjunctivalFlap in Patients ndergoing Trabeculectomy with Intra-operative Mitomycin C admitted at Ophthalmology Unit, KIOMS, Lady Read- Table-2: Pre-operative Intraocular pressure
ing Hospital, Peshawar. Eighty eyes of eighty patients with respect to procedures (n=80)
were included in the study and it was conducted from among these 80 patients 45 (56.3%) were male and 35 (43.8%) were female patients, as shown in figure 1. The mean age was 54.1 years with ± standard deviation of 5.6. The youngest was 32 years and the oldest was 60 IOP=Intraocular pressure years as shown in table 1. In 80 eyes trabeculectomy Table-3: IOP on 1st Post-Operative day
with limbal based conjunctival flap and intra-operative with respect to procedures (n=80)
Mitomycin C (MMC) was performed as primary proce- dure. At presentation the IOP was ranged from 24-32 mmHg, with mean of 27.28 mmHg with ± 2.32 stand- IOP= Intraocular pressure ard deviation. Intraocular distribution is given in table 3. Among these 80 patients right eye was involved in Table-4: IOP on 10th Post-Operative day
39 (48.8%) and left eye was involved in 41 (51.3%) as with respect to procedures (n=80)
shown in figure 2. After full assessment, patients had postoperative follow up of one month. During this pe- riod intraocular pressure and bleb formation were as- Key.IOP= intraocular pressure sessed at 1st day, 10th day and 30th day postoperatively. Table-5: IOP on 30th Post-Operative day
Postoperative intraocular pressure (IOP) was assessed. with respect to procedures (n=80)
Mean IOP on day 1st, day 10th and day 30th was 11.17, 12.1 and 12.12, as shown in table 4, 5 and 6. Bleb forma- tion was assessed postoperatively on day 1st, day 10th Key:n= total number of eyes and day 30th i.e. 85%, 100% and 100% as shown in table IOP= Intraocular pressure 7 and 8. In my study final mean IOP was12.12 ± 0.68. Table-6: Bleb formation on 1st postoperative
day with respect to procedures (n=80)
Bleb formed Bleb Not formed
Key: n= total number of eyes Table-7: Frequency of bleb formation on 10th
post-operative day with respect to procedures (n=80)
Bleb formed
Bleb Not formed
Figure-1: Distribution of cases by Gender
Key: n= total number of eyes Table-8: Bleb formation on 30th post-operative
day with respect to procedures (n=80)
Bleb formed
Bleb Not formed
Key. n= total number of eyes This study was conducted in Ophthalmology De- partment, Khyber Institute of ophthalmic Sciences/ Lady Reading Hospital, Peshawar. In this study eighty eyes of glaucoma patients were included. The surgical Figure-2: Distribution with respect to Eye Involved (n=80)
management of glaucoma has progressed and evolved throughout the years. With advances in surgical tech- Table-1: Age Distribution (n=80)
nique, such as the use of adjunctive antifibrotic or an- Age(years) Minimum Maximum
timetabolic agents and the placement of adjutable su- tures, glaucoma surgery has become a more reliable Ophthalmology Update Vol. 13. No. 2, April-June 2015 The Efficacy of Limbal Based ConjunctivalFlap in Patients ndergoing Trabeculectomy with Intra-operative Mitomycin C and predictable undertaking.10 Trabeculectomy with my with limbal based conjunctival flap and MMC, MMC augmentation is a safe and effective procedure as the chances of bleb non-formation due to leak- for reduction of IOP and visual rehabilitation whether a age is more common on 1st postoperative day in fornix- or a limbal-based conjunctival flap is utilized.10 the latter procedure.
My study presents outcome data comparing the • Surgical procedure is cost effective and reduces limbal flap design in trabeculectomy procedures. In the use of lifelong antiglaucoma drugs. Drugs side this study 45 (56.3%) of patients were male and 55 effects can be avoided with surgical procedures. (43.8%) were female. In a study by A Alwitry,10 28 were Surgery should better be performed by an experi- male and 31 were female. In a study by Susan JLee,11 70 (45.2%) were male and 85 (54.8%) were female. In a study by WL Membrey,12 21 were male and 52 were Durrani J. Taking up the gunlet against the gruesome grave glaucoma [Editorial]. Pak J Ophthalmol 2000;2:67-9.
female. In my study mean age is 54 years (32-60) +/- Thylefors B, Negral AD, Pararajasegaram R, Dadzie KY. Global 5.63.In a study by A Alwitry,10 mean age was 69.74 data on blindness. Bull World Health Org 1995;73:115-21.
years (23-85years). In a study by Tham CC1,3 mean age Qureshi MB, Khan MD, Shah MN, Ahmad K. Glaucoma ad- missions and surgery in public sector tertiary care hospitals in was 48.1years +/- 21.9.In a study by Susan L Jee11, The Pakistan: results of a national study. Ophthalmic Epidemiol mean patient age was 65.4 years (range, 18–89 years). Preoperative intraocular pressure (IOP) was measured Babar TF, Saeed N, Masud Z, Khan MD. A two years audit of glaucomas in admitted patients at Hayatabad medical complex with mean IOP ± SD of 27.15 ± 2.60 mmHg. In a study Peshawar. J Postgrad Med Inst 2004;18:284-92.
by A Alwitry,10 mean IOP in Limbal based group was S Fraser. Trabeculectomy and antimetabolites. Br J Ophthal- 26.09mmHg+/-7.71. In a study by Zdravko Mandic,14 mol. 2004;88:855– 6.
Watson PG. Trabeculectomy, a modified ab externo technique. the mean IOP in Limbal based trab was 22.4 +/- 4.5 Ann Ophthalmol 1970;2:199-205.
mmHg. While bleb was formed in 85%, 100% and 100% , . A randomised, prospective of patients on 1st, 10th and 30th postoperative day re- study comparing trabeculectomy with viscocanalostomy with adjunctive antimetabolite usage for the management of open spectively. In a study by Henderson,15 leaked was seen angle glaucoma uncontrolled by medical therapy. in 10 out of 41 limbus based flaps (24%) on the 1st post- 2004;88:1012-7.
operative day. In a study by Wu L,16 bleb was functional Long-term outcomes of intraoperative 5-fluorouracil versus in- in 90.4%. In a study by F Grehn,17 6 out of 30 filtering traoperative mitomycin C in primary trabeculectomy surgery. blebs (20%) of the Limbus-based trab. were judged as 2009;116:185- 90.
avascular. In my study Postoperative IOP in Limbal based group was 11.17 ± 2.2 on 1st postoperative day, cin C for glaucoma In a study by A Alwitry,10 mean IOP was 10.86 +/- 5.98.
10. A Alwitry, V Patel, AW King. Fornix vs limbal-based trab- In my study mean IOP on 10th postoperative day was eculectomy with mitomycin C.Eye 2005; 19: 631–636.
12.1 ± 0.68. In a study by A Alwitry, 11. Susan J Lee,Augusto Paranhos,M Bruce Shields.Does titration of mitomycin C as an adjunct to trabeculectomy significantly 8.85 +/- 4.35. In my study final mean IOP was12.12 ± influence the intraocular pressure outcome? Clin Ophthalmol 0.68, In a study by A Alwitry,10 mean IOP was 13.30 +/- 2009;3:81- 7.
8.23. In a study by Zdravko Mandic1, 12. W L Membrey, D P Poinoosawmy, C Bunce, R A Hitchings. Glaucoma surgery with or without adjunctive antiprolifera- 15.9 +/- 3.2 mmHg. In a study 18 the limbus- tives in normal tension glaucoma: 1Intraocular pressure con- based conjunctival flap group, 146 eyes (97%) achieved trol and complications. Br JOphthalmol 2000; 84: 586–90.
an IOP of less than 20 mm Hg.
13. Tham CC, Lai JS, Poon AS,Lai TY, Lam DS .Resul trabeculec- tomy with adjunctive intraoperative mitomycin C in Chinese patients with glaucoma. • Glaucoma is a common vision threatening condi- tion affecting both sexes. 14. Mandiæ Z , Benèiæ G , Geber M Z , Bojiæ L . Fornix vs Limbus Based Flap in Phacotrabeculetomy with Mitomycin C: Prospec- • It is more likely occur in older individuals.
tive Study.Croatian Medical Journal 2004; 45:275-278.
• Patients present with different types of signs and 15. H W A E I E . Early postoperative symptoms depending upon the type of glaucoma. trabeculectomy leakage: incidence, time course, severity, and impact on surgical outcome: Br J Ophthalmol 2004; 88:626-629.
The most common of which is decreased visual 16. Wu L,The effect of mitomycin C on filtration surgery of glaucoma with poor prognosis. Zhonghua Yan Ke Za Zhi • In our setup patients usually presents with ad- vance disease, so the treatment of choice is sur- of combined procedures for glaucoma and cataract: II. Limbus- gical intervention due to late presentation, poor based versus fornix-based conjunctival flaps : drugs compliance and poverty.
18. Grehn F, Mauthe S, Pfeiffer N . Limbus-based versus Fornix- • Trabeculectomy with fornix based conjunctival based conjunctival flap in filtering surgery: International Oph- flap and MMC is more effective than trabeculecto- Ophthalmology Update Vol. 13. No. 2, April-June 2015 Normal Tension Glaucoma &
Cerebral Ischemia / Brain Atrophy
Akhunzada M. Aftab Akhunzada Muhammad Aftab FCPS1, Awais Rauf MBBS2, Asif MBBS3 Prof. Mustafa Iqbal FRCS, FRCOphth4, Sobia Sabir Ali FCPS5, Atif Rana FCPS6 Purpose: To find incidence of cerebral ischemia and (or) brain atrophy in patients diagnosed as normal tension glaucoma
using magnetic resonance imaging.
Materials and Methods: Patients diagnosed with Normal Tension Glaucoma were admitted and underwent 2 hourly IOP
phasing for 24 hours to exclude unrecognized IOP spikes. Detailed ophthalmological examination including visual acuities, best corrected visual acuity, pupils examination, IOP measurement, gonioscopy, optic disc and fundus examination was carried out on all patients. Humphrey Visual Field analysis and Central Corneal Thickness (CCT) was done and correction factors were applied to all IOP readings. All patients underwent an MRI Brain and Orbits without contrast. T1, T2 and FLAIR images were obtained and reported by a consultant radiologist. Hematological and other radiological investigations were done to exclude other causes of cerebral ischemia.
Results: Total number of patients in this study was 19. Most patients included in our study were females(63%). Mean age
was 60 years (range 42- 75 years). None of the study patients recorded a corrected IOP reading of more than 21 mmHg on phasing. MRI imaging revealed 15 (79%) patients having cerebral ischemic changes and (or) brain atrophy. In these patients, 10 had cerebral ischemic changes including small lacunar infarcts, while 5 patients were reported as having gross brain atrophy with small vessel ischemic changes in brain.
Conclusion: The study suggests a greater incidence of cerebral ischemia and (or) brain atrophy in patients with normal-
tension glaucoma. • Impaired vascular auto regulation (prolonged Glaucoma encompasses a heterogeneous group of arteriovenous venous passage time in relation to conditions, resulting in optic nerve damage and charac- ocular perfusion)4 teristic visual field changes. It is usually but not always associated with raised intraocular pressure (IOP). Nor- • Peripheral vasospasm, Raynaud syndrome mal-tension glaucoma (NTG) is a chronic optic neu- • Autoimmune disorders ropathy with features similar to primary open-angle • Systemic vascular disease (i.e. atherosclerotic dis- glaucoma (POAG), with the exception of a consistently ease, cerebrovascular insufficiency)5,6 normal IOP, i.e. less than 22 mm Hg.1 The disease usu- • Systemic nocturnal hypotension ally presents in old age and has a female predilection. • Sleep apnea (decreases oxygen saturation)7 The exact etiology of NTG is uncertain and various risk Cerebral ischemia and (or) brain atrophy is a rec- factors have been postulated. These include: ognized risk factorand researchers are taking keen in- • Generalized peripheral vascular endothelial dys- terest in this hypothesis. Optic nerve being a part of the central nervous system is affected in the same way • Ocular circulation insufficiency (lower ocular as the brain. This theory is supported by some studies pulse amplitude)2 which have found a significant portion of patients diag- • Increased resistance index in the central retinal ar- nosed as NTG to have cerebral ischemia and (or) brain tery (role in progression of visual field defect)3 atrophy. In our department, we investigated patients 1Registrar Eye A Unit Department of Ophthalmology, Khyber Teaching diagnosed as normal tension glaucoma for occurrence Hospital, Peshawar. 2,3Trainee Medical Officers. A Unit Department of of concurrent cerebral ischemia and (or) brain atrophy Ophthalmology, Khyber Teaching Hospital, Peshawar. 4Prof. & Head using magnetic resonance imaging. of Ophthalmology, 5Head of Endocrinology Department. 6Consultant Radiologist, Shifa International Hospital MATERIAL AND METHODS
Patients diagnosed with normal tension glaucoma Correspondence: Dr. Akhunzada Muhammad Aftab c/o Prof. were included in the study. All patients were admitted Dr. Muhammad Ibrar, Department of Botany, University of Peshawar, Peshawar. Cell: 03339106060, E-Mail: and underwent 2 hourly IOP phasing for 24 hours to exclude unrecognized IOP spikes. Detailed ophthalmo- Received: February 2015 Accepted: February 2015 logical examination including visual acuities, best cor- Financial Disclosure: There has been no financial interest involved rected visual acuity, pupils examination, IOP measure- in this study ment, gonioscopy, optic disc and fundus examination Ophthalmology Update Vol. 13. No. 2, April-June 2015 Normal Tension Glaucoma & Cerebral Ischemia / Brain Atrophy was carried out on all patients. Humphrey visual field analysis and central corneal thickness (CCT) was done and correction factors were applied to all IOP readings. Hematological investigations included Full blood count, prothrombin time (PT), activated partial throm- boplastin time (APTT), HbA1c and fasting lipid profile. Other investigations included 8- hourly blood pressure monitoring, ECG, echocardiography and carotid dop- pler scans. All patients underwent an MRI brain and orbits without contrast. T1, T2 and Flair images were obtained and reported by a consultant radiologist who was unaware of the diagnosis of the patients. Concur- Figure-2: MRI Brain findings in our study.
rent conditions like diabetes, hyperlipdemia and hy- pertension were actively managed in consultation with an endocrinologist and a cardiologist.
The exact patho-physiology causing optic nerve damage in normal tension glaucoma is still uncertain Our study included 19 patients. Male patients in- and a matter of ongoing debate. Intra ocular pressure, cluded in our study were 7 (37%) while there were 12 the only factor with other types of glaucoma has in (63%) females. Mean age was 60 years (range 42- 75 common is not related to this condition. Probably that years). None of the study patients recorded a corrected is the reason why anti glaucoma medications, which IOP reading of more than 21 mmHgon phasing. Two lower the IOP have not been proven effective in halt- (10%) patients suffered from diabetes, 10 (53%) patients ing the progression of the disease process. Stroman had hypertension while 5 (26%) patients were diag- GA et al. reported an increased incidence of cerebral nosed as both diabetic and hypertensive. One (5%) pa- small vessel ischemia in patients with normal tension tient in our study group had raised triglyceride levels.
glaucoma compared to control subjects and proposed There were 2 (10%) patients with history of migraine. the theory of vascular damage of optic nerve in these None of the study patients was reported to have sleep patients.6 Another study conducted at The Sydney Eye Hospital, Australia compared MRI of brain of patients Echocardiography revealed abnormalities in 6 with NTG with control subjects. They concluded that (32%) patients. These included diastolic dysfunction in patients with NTG had increased incidence of cerebral 3 patients. Mild mitral valve regurgitation was report- infarcts, the thickness of the body and genu of corpus ed in 2 patients while one patient had mild aortic valve callosum was thinner as compared to control subjects. regurgitation. Carotid Doppler scans did not reveal They also postulated an ischemic patho-physiologic ba- significant stenosis (>75%) in any of the study patients. MRI imaging revealed 15 (79%) patients having cere- Optic nerve damage and progression of visual bral ischemic changes and (or) brain atrophy. In these fields loss also seems to be related to cerebral ischemia. patients, 10 had cerebral ischemic changes including small lacunar infarcts, while 5 patients were reported as In NTG patients with cerebral ischemia on MRI, the having gross brain atrophy with small vessel ischemic visual fields showed deeper depression in the inferior changes in brain.
pericentral visual field and has been marked as an in- dependent risk factor for visual fields progression in such cases.9, 10 In a study, conducted by Suzuki J. et al at the university of Tokyo School of Medicine, 32 out 94 patients with NTG has ischemic changes on MRI. In our study we also concluded that a significant num- ber (79%) of patients diagnosed as NTG had signs of cerebral ischemia and (or) brain atrophy indicated on magnetic resonance imaging of brain and visual path- way. This further acknowledges the hypothesis that is- chemic damage occurring in the brain of patients with NTG is responsible for optic nerve damage as well, as both share common blood supply (Carotid system) and Figure-1: Associated risk factors in patients diagnosed with NTG
hence is subjected to similar insults.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Normal Tension Glaucoma & Cerebral Ischemia / Brain Atrophy blood flow and central visual function in primary open-angle The study suggests a greater incidence of cerebral glaucoma. J Glaucoma. 2007 Jan;16(1):159-63 ischemia and (or) brain atrophy in patients with nor- Stroman GA, Stewart WC, Golnik KC, Curé JK, Olinger RE. Magnetic resonance imaging in patients with low-tension glau- mal-tension glaucoma. Optic nerve damage in such pa- coma. Arch Ophthalmol. 1995 Feb;113(2):168-72 tients may be an extension of the same disease process.
Bilgin. Normal-tension glaucoma and obstructive sleep ap- REFERENCES
nea syndrome: a prospective study. BMC Ophthalmol. 2014 Kim M, Kim TW, Park KH, Kim JM. Risk factors for primary open-angle glaucoma in South Korea: the Namil study. Jpn J Ong K, Farinelli A, Billson F, Houang M, Stern M. Comparative Ophthalmol. 2012 Jul;56(4):324-9 study of brain magnetic resonance imaging findings in patients Su WW, Cheng ST, Hsu TS, Ho WJ. Abnormal flow-mediated with low-tension glaucoma and control subjects. Ophthalmol- vasodilation in normal-tension glaucoma using a noninvasive ogy. 1995 Nov;102(11):1632-8.
determination for peripheral endothelial dysfunction. Invest Suzuki J, Tomidokoro A, Araie M, Tomita G, Yamagami J, Ophthalmol Vis Sci. 2006 Aug;47(8):3390-4 Okubo T, Masumoto T. Visual field damage in normal-tension Delaney Y, Walshe TE, O'Brien C. Vasospasm in glaucoma: clin- glaucoma patients with or without ischemic changes in cere- ical and laboratory aspects. Optom Vis Sci. 2006 Jul;83(7):406-14 bral magnetic resonance imaging. Jpn J Ophthalmol. 2004 July- Plange N, Kaup M, Remky A, Arend KO. Prolonged retinal Aug; 48(4): 340-44 arteriovenous passage time is correlated to ocular perfusion 10. Leung DY, Tham CC, Li FC, Kwong YY, Chi SC, Lam DS. Si- pressure in normal tension glaucoma. Graefes Arch Clin Exp lent cerebral infarct and visual field progression in newly diag- Ophthalmol. 2008 Aug;246(8):1147-52 nosed normal-tension glaucoma: a cohort study. Ophthalmol- Harris A, Siesky B, Zarfati D, et al. Relationship of cerebral ogy. 2009 Jul;116(7):1250-6.
Tuberous sclerosis complex (TSC) is an autosomal dominant neuro- cutaneous disease (phacomatosis) with variable clinical manifestations (see the main article) Curtesy: Dr Hussain Ahmad Khaqan Department of Ophthalmology, Lahore General Hospital/PGMI, Lahore.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Complications & Results of
External Dacryocystorhinostomy in Chronic
Dacryocystitis without Intubation
(Review of 107 Cases.)
Mohammad Alam FCPS1, Misbah Durrani FCPS2, Prof. Lal Mohammad FCPS3 Arshad Farooq FCPS4 Objective: To find out complications and results of external dacryocystorhinostomy without tube intubation in chronic
dacryocystitis (CDC).
Materials and methods: This prospective study was conducted in eye care centre Karak and K.D.A Teaching Hospital
Kohat from March, 2008 to March, 2014. 107 patients suffering from chronic dacryocystitis were selected with age range from 31 – 63 years with mean age 44.7 years. Out of 107 patients, 63 (58.87%) were male and 44(41.12%) were female. Indications for dacryocystorhinosyomy was epiphora and chronic dacryocystitis. Diagnosis was done on regurgitation test and syringing of nasolacrimal duct system. All patients were operated under local anesthesia. External approach was done and only anterior flap was made. Dacryocystorhinostomy was done without silicone tube intubation. Postoperative syring- ing was done on the table, 10 days, 3 months and 6 months. Successful outcome was defined as relief from epiphora after dacryocystorhinostomy and patent nasolacrimal duct on syringing.
Results: After six months 95 (88.78%) was the success rate. Epiphora was present in 7(6.54%) patients and epiphora with
discharge was present in 5(4.67%). 11(10.28%) patients had nasal mucosal bleeding, 9(8.41%) had nasal bone bleeding and tear in nasal septum was observed in 2(1.86%)patients peroperatively. Postoperatively 9(8.41%) patients had wound infection with cellulitis, 4 (3.73%) patients had bleeding from nose and 13(12.14%) patients had periorbital ecchymosis. All these complications resolved within 10 days.
Conclusion: External dacryocystorhinostomy is a safe procedure under local anesthesia. This technique has high success
rate. Complications are minimal and can be easily managed.
Key word: chronic Dacryocystitis, Epiphora, External Dacryocystorhinostomy.
Abbreviations: Chronic Dacryocystitis (C.D.C), Dacryocystorhinosyomy (D.C.R) Nasalacrimal Duct (N.L.D)
with this gold standard procedure.4 Various studies NLD blockade results in watering of disturbed have reported external DCR success rate more than tears called Epiphora which is the most bothersome 80% which depends upon the surgeon experience.
problem of lacrimal system obstruction. Management There are other methods of surgical procedure to of Epiphora has evolutionary history. Adeo Toti was treat NLD obstruction. These include endoscopic DCR, the first who introduced dacryocystorhinostomy for endoscopic laser nasal DCR, endoscopic radio frequen- the treatment of epiphora.1 He created an external ap- cy assisted DCR.5,6,7 Endoscopic DCR is the favored sur- proach to lacrimal sac by creating a window in nasal gical procedure of ENT surgeon and thus ophthalmolo- lateral wall. The results of Adeo Toti were not success- gists and ENT surgeons share their clinical skill and ful in many patients. This procedure was modified by experience in care and treatment of NLD obstruction Bourguet and Dupuy-Dutemps. They introduced anas- patients.8 There are numerous modifications in various tomosis of mucosa with suturing of the mucosal flaps.2 surgical steps that has been introduced in DCR over Ohm added suturing of anterior and posterior flaps of years to get better results. Various national and inter- nasal mucosa with lacrimal sac.3 External DCR is the national studies have reported low complications rate mostly practiced operation for NLD obstruction. Usu- in external DCR. We present our experience in external ally other methods of surgery for CDC are compared DCR with only anterior flaps suturing.
MATERIALS AND METHODS
1.Assistant Professor Ophthalmology KMU Institute Of Medical This prospective study was conducted in Eye Sciences, K.D.A Kohat. 2Assistant Professor, Radiology, Bacha Khan Care Centre Karak and KDA Teaching Hospital Kohat Medical College, Mardan. 3Professor of Ophthalmology KMU Institute of Medical Sciences, K.D.A Kohat. 4Assistant Professor ENT KMU- from March, 2008 to March, 2014 with the objective to Institute of Medical Sciences, KDA Kohat know the success rate and complications of external Correspondence: Dr. Mohammad Alam1 Assistant Professor DCR without silicone tube intubation. Total 107 pa- Ophthalmology KMU Institute of Medical Sciences K.D.A Kohat. tients with age range of 31 to 63 years with mean age of 44.7 years were selected table I. Out of 107 patients 63 Received: December 2014 Accepted: February 2015 (58.87%) were male and 44 (41.12%) were female (Ta- Ophthalmology Update Vol. 13. No. 2, April-June 2015 Complications & Results of External Dacryocystorhinostomy in Chronic Dacryocystitis without Intubation ble II). Indications for DCR were epiphora and chronic Table-II: Gender Distribution
dacryocystitis. Diagnosis of all patients was made by Number of patients
regurgitation test and syringing of NLD system.
• CDC patients with Regurgitation test positive and NLD blocked by syringing.
Table-III: Complications during surgery
Number of patients
• Hypertensive Patients Canalicular obstruction Nasal mucosal bleeding • Nasal trauma patients • Previously operated DCR Nasal bone bleeding All the patients were operated under local anes- Tear in nasal septum thesia. Nasal packing in all the patients was done with Table-IV: Immediate postoperative complications
gauze soaked in 4% Xylocaine and 1 in 100000 adrena- line. Lacrimal sac area was infiltrated with 2% xylocaine of patients
with 1 in 100000 adrenaline. DCR was done with Bour- Wound infection with cellulitis guet and Dupey-Dutemps Technique. Anterior and pos- Postoperative Bleeding terior flaps of the lacrimal sac and nasal mucosa were made. Posture flaps were excised and anterior flaps were sutured together to form bridge. Muscle layers were approximated with stitches. Skin stitches were ap- No of Patients
plied. After skin stitches homeostasis was secured. Na- sal pack was removed and syringing of the NLD sys- tem was done on the table. Haemostasis was secured on Epiphora with discharge the table. Patients were put on systemic antibiotic pain killer and topical antibiotic ointment for application on wound and antibiotic drops in eye for 10 days. Syring- ing was done with follow up on 10 day one month, 3rd month and 6th month. Successful results were considered In our study results had success rate of 88.78% to be negative regurgitation test and on syringing pat- and complications were found being managed early. ent NLD along with patients satisfaction. Moreover in our patients male were more than female. Our study has some similarities to National and Inter- During surgery bleeding from nasal mucosa was national studies. But also variations were found in vari- observed in 11 (10.28%) patients nasal bone bleed- ous aspects of the patients after complete follow up.
ing from 9 (8.41%) patients, tear in nasal septum in Emed S M H has reported success rate of 88.7% 2(1.86%)patients. Regarding immediate/early postop- of external DCR without intubation which is similar erative complications bleeding in 4 (3.73%) periorbi- to our study, but in his study female were more than tal swelling/ecchymosis in 13 (12.14%) patients while male.9 Complications reported are also negligible in his wound infection with cellulitis was observed in 9 (8.4%) study. Rehman A, Channa S have reported 97.77% suc- cess rate of external DCR without intubation but they Regarding results of success, over all 95 (88.78%) had used mitomycin C during surgery.10 Probably this DCR were successful, while in 7 (6.5%) patients epi- may be due to mitomycin C. Besharati MR, Rastigor A phora was present on subsequent follow up and epi- have reported in their study of External DCR success phora with discharge was present in 5 (4.67%) patients rate of 88% and failure rate of 9.6%, wound infection (Table V). In these 12 patients on syringing NLD was in 5.3% and granuloma formation in 3.2% patients. The observed blocked.
results are comparable to our study.11 Darade DM. Sa- Table-I: Age distribution
hasrabudhe VM, Khaire BS et al have reported in exter- Age in Years
No of Patients
nal DCR success rate of 96.25% and also in their study female patients were more than male. Complication rates were also less. All these results depend upon the etiology of CDC and surgical expertise 12Silicone tube is not necessary in CDC if obstruction is below the cana- licular level.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Complications & Results of External Dacryocystorhinostomy in Chronic Dacryocystitis without Intubation HO Kyung Choung and Sang In Khwarg study re- 72 (6): 703-6.
veals 100% anatomic patency results in external DCR. Yazici Z Yazici B, Paarlak M, Ertirk H, Savi G. Treatment of However, epiphora was present in 6.7% patients de- obstructive epiphora in adult by balloon dacryocystoplasty. Br J Ophthalmol 1999; 83 (6): 692-6.
spite of anatomic patency of NLD.13 Muhammad Al 6. Moore WM, Bentley Cr, Olver JM. Functional & anatomic re- Droos study on external DCR reveals female to be more sults after two types of endoscopic endonasal dacryocystorhi- than male and the complications reported are more than nostomy: surgical and holmium laser. Ophthalmology 2002; 109 (8): 1575-82.
our study like transient lagophthalmos, wound dehis- Unlu HH, Toprak B, Aslan A, Guler C. Comparison of surgical cence and Transient orbicularis hypotony.14 Tsirbas A, outcomes in primary endoscopic dacryocystorhinostomy with Mc Nab had demonstrated secondry haemorhage in and without intubation. Ann Otol Rhinol Laryngol 2002; 111 external DCR in 10 patients out of 293 DCR, which has Al.shaikh S,Javed F,et al.UK Survey of the present role of ear, not been found in our study. They have also shown a nose and throat surgeons in lacrimal surgery.Ann R Coll Surg failure rate of 8.5%.15 Now-a-days endoscopic DCR is also in practice but the results of success rate is not as Emad SMH.Comparison of results and complications of ex- in external DCR.
ternal dacryocystorhinostomy with and without silicone tube.
Whitaker JKH, Hall AB, Dhalla KH JBUMS 2008 ,10(5):62-67.
have reported success rate in discharge and epiphora 10. Rehman A,Channa S,Niazi JH et al.Dacryocystorhinostomy resolution to be 90.9% and 84.4% patients with external without intubation with inraoperative mitomycin-C. jour- DCR.16 Mekonnen W, Adanbu Y have shown 93% suc- nal of the college of Physician and Surgeon Pakistan: JCPSP cess rate of external DCR.
17 Zaman M, Babar TF, Saeed 11. Besharati MR,Rastegar A. Results and complications of exter- N have reported over all success rate of 98.33% in ex- nal dacryocystorhinostomy surgery at a teaching hospital in ternal DCR. The success rate of this study is high than Iran.Saudi Med J.2005.Dec;26(12):1940-4.
our study. However the complications mentioned in 12. Darade DM,Khaire BS,et al. Outcome of Modified Anterior Flaps Anastomosis Technique of External Dacryocystorhinos- the study are comparable to our study.18 tomy.Medical Science Vol 4 issue 11.Nov 2014.
13. Choung HK,Khwarg SI.Selective non-intubation of a silicone External DCR is the most popular and fruitful sur- tube in external dacryocystorhinostomy. Acta Ophthalmol.
gical procedure with high success rate and less com- 14. Aldroos M.Postoperative external dacryocystorhinostomy plications. This procedure has short learning curve. It complications. Int J Biol Med Res. 2013; 4(2): 3066 – 3069.
can be performed on local anesthesia and in most cases 15. Tsirbas A.and McNab,A.A(2000),Secondary haemorrhage after intubation is not necessary.
DCR. Clinical & experimentalOphthalmology. Volume 28, Is- sue 1,(/doi/10.1111/ceo.2000.28.issue-/issuetoc)pages 22 – 25, Toti A. Nuovo metodo conseravative di cura radicalle delle February 2000.
supporazioni chronicle del sacco lacrimale Clin Mod Firenze 16. Whitaker JKH, Hall AB Dhalla KH. Outcomes and reasons for 1904;10: 385-9.
DCR at KCMC,aTanzanian referral Hospital,2001-2006.African Dupuy-Dutemps L, Bourguet J. Procede plastique de dacryo- cystorhinostomie et ses resultants. Ann Ocul J 1921; 158: 241-61.
17. Mekonnen W, Adamu Y. Outcome of external dacryocystorhi- Ohm J. Nerbesserungen an meinen Nystagmographen. Klin nostomy in Ethopian patients Ethiop Med J 2009; 47:221-6.
Monatsble Augenheilk 1926; 1:791-4.
18. Zaman M,Babar TF ,Saeed N. A review of 120 cases of dacryo- Seppa H, Grenman R, Hartikainen J. Endonasal Co -Nd: YAG cystorhinostomies (Dupuy Dutemps and Bourguet Technique.J laser dacryocystorhinostomy. Acta-ophthalmol Copenh. 1994; Ayub Med Coll Abbottabad.2003 Oct-Dec;15(4):10-2.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Recurrence of Retinal Detachment
after Silicone Oil Removal
Bilal Khan FCPS1, Mumtaz Alam FCPS2, Bilal Bashir FCPS3, Adnan Alam MBBS4 Mir Ali Shah FCPS5, Mehfooz Husssain FRCS6 Objective: To find out the frequency of recurrence of retinal detachment after silicone oil removal
Materials and Methods: This is a retrospective review of 100 patients. The study was conducted in the Department of Oph- thalmology, Lady Reading Hospital Peshawar. All patients who underwent removal of silicone oil from the eye between June 2012 and January 2014 were included in the study. Silicone oil was removed via pars plana sclerotomies in all patients un- der peribulbar anesthesia. All surgeries were performed by the same surgeon. The mean follow up period after the removal of silicone oil was 6 months.
Results: 65 of the patients were male (65%) and 35 were female (35%). Age of the patients was ranging from 16 to 70
years, with a mean of 37 years. The duration of intraocular silicone oil tamponade ranged from 3 to 6 months. Retina was attached in all cases before the removal of silicone oil. 6 months after the removal of silicone oil, retina remained attached in 75 of the 100 (75%) patients included in the study. In 25 (25%) patients, the retina detached after removal of silicone oil.
Conclusion: Re-detachment of the retina can occur after removal of silicone oil in eyes having stable attached retina after
successful pars plana vitrectomy with silicone oil tamponade. Detail assessment of the patient is important to identify the eyes at risk of re-detachment.
Keywords: Proliferative diabetic retinopathy, Retinal Detachment, Silicon oil, Sulpher hexafluoride.
based on the experimental work of silicone.3 Silicone The retina is an extremely thinnest tissue of the oil is used in vitreoretinal surgery to provide long-term eye. Most retinal detachments are a result of a retinal internal tamponade in cases of rhegmatogenous reti- break, hole, or a tear. Retinal breaks, holes, or tears are nal detachment complicated by severe proliferative vit- not the result of trauma, but are due to pre-existing fac- reoretinopathy (PVR) and giant retinal tears,4,5 severe tors such as high levels of myopia and prior ocular sur- proliferative diabetic retinopathy (PDR), chronic uvei- gery. Early diagnosis and repair of retinal detachments tis with profound hypotony, selected cases of macular is urgent since visual improvement is much greater hole, infectious retinitis, and vitreous hemorrhage after when the retina is repaired before the macula or central penetrating ocular trauma.
area is detached.
Silicone oil is generally removed after 6 months if Silicone compounds are unique materials both in the retina is attached and must be removed upon the terms of the chemistry and in their wide range of useful development of oil emulsification, keratopathy, sec- applications. Silicone in combination with organic com- ondary glaucoma or cataract.6 Compared with sulphur pounds provides unique properties that function over hexafluoride gas (SF6) as an intraocular tamponade for a wide temperature range, making the silicone based the management of retinal detachment, eyes treated products less temperature sensitive than most organic with silicone oil are more likely to be successfully re- attached, to achieve a better visual acuity, and to have The use of silicone oil in retinal re-attachment fewer postoperative complications, particularly cata- surgery was introduced by Paul Cibis2 in early 1960s, ract, glaucoma, and keratopathy.7 The purpose of our study was to find out the recurrence rate of retinal de- 1,3Vitreo-Retina Trainee, Lady Reading Hospital Peshawar. 2Assistant tachment after silicone oil removal. Professor, Ophthalmology Department Peshawar Medical College Peshawar. 4Trainee Medical Officer, Lady Reading Hospital Pesha- MATERIAL AND METHODS
war. 5Associate Prof. Lady Reading Hospital Peshawar. 6Assistant This was a retrospective review of 100 patients. Prof. Lady Reading Hospital Peshawar The study was conducted in the Department of Oph- Correspondence: Dr. Bilal Khan Department of Ophthalmology, Lady thalmology, Lady Reading Hospital Peshawar. All pa- Reading Hospital Peshawar. Mob No: 0300-5981806 tients who underwent removal of silicone oil from the eye between June 2012 to January 2014 were included Reeived: January 2015 Accepted: February 2015 in the study. All patients included in the study had pre- Sponsoring organization: None viously undergone pars plana vitrectomy using a three Ophthalmology Update Vol. 13. No. 2, April-June 2015 Recurrence of Retinal Detachment after Silicone Oil Removal port technique. Pars plana vitrectomy with silicone oil tached after removal of silicone oil. Of these 25 eyes, 17 endo-tamponade was carried out with endo-drainage eyes had proliferative vitreo-retinopathy (PVR), 7 eyes of sub-retinal fluid, use of perfluorocarbon liquids, en- had proliferative diabetic retinopathy and 1 eye had dolaser coagulation, cryopexy and relaxing retinoto- uncomplicated rhegmatogenous retinal detachment. mies. In all patients, silicone oil with a viscosity of 1000 Incomplete removal of the vitreous base, defined as centistokes was used. Before removal of the silicone oil, ophthalmoscopically visible remnants of the vitreous the retina was attached in all patients. Silicone oil was base before removal of silicone oil, was significantly removed via pars plana sclerotomies in 100 patients higher in patients with retinal re-detachment than in under peribulbar anaesthesia. All surgeries were per- patients without postoperative retinal detachment.
formed by the same surgeon. The mean follow up pe- riod after the removal of silicone oil was 6 months.
Since the invention of the vitrectomy instrument, the role of silicone oil as a vitreous substitute and reti- 65 of the patients were male (65%) and 35 were fe- nal tamponade has expanded. The beneficial effects of male (35%). Figure I shows the gender distribution of silicon oil have been confirmed in a multicenter clinical patients. Age of the patients was ranging from 16 to 70 trial by the silicon oil study group. More recently, the years, with a mean of 37 years. Table I shows the age beneficial effects of silicone oil have been re-confirmed distribution of patients. The duration of intraocular sili- in a multicenter clinical trial by the silicone oil study cone oil tamponade ranged from 3 to 6 months. Retina was attached in all cases before the removal of silicone We did a retrospective review of 100 patients who oil. 6 months after the removal of silicone oil, retina underwent removal of silicone oil from the eye, in the remained attached in 75 of the 100 (75%) patients in- Department of Ophthalmology Lady Reading Hospital cluded in the study. In 25 (25%) patients, the retina de- Peshawar, between June 2012 and January 2014 and had completed 6 months follow up. The retina was at- tached and stable in all cases before silicon oil removal. 6 months after the removal of silicone oil, retina re- mained attached in 75 of the 100 (75%) patients includ- ed in the study. In our study the retinal re-detachment rate after the removal of silicone oil was 25% which is almost similar to some other published reports on sili- cone oil removal before emulsification.10,11,12 Figure-I: Gender distribution of patients
The cause of this re-detachment following silicone Table-I: Age distribution of patients
oil removal was mostly residual traction and redevel- opment of proliferative vitreo-retinopathy that had led Number of patients
to reopening of pre-existing retinal breaks, or formation of new retinal breaks as a result of surgical manipula- The reported incidence of retinal re-detachment after silicone oil removal is highly variable.11,13 This variation is most probably due to marked differences in the number of eyes studied, the duration of follow-up Table-II: Recurrence of retinal detachment after
silicone oil removal in various studies
after silicone oil removal, and the underlying diseases.
Anatomical success after silicone oil removal, de- Percentage
Journal & Year
fined as complete retinal attachment was achieved in Pavlovic S et al19 Ophthalmology 1995 75 (75%) out of 100 eyes in this study, whereas, retinal Acta Ophthalmol Scand re-detachment after silicone oil removal was seen in the Acta Ophthalmol Scand remaining 25%. Falkner et al reported 17.4% cases of re-detachment after silicone oil removal in their study.14 Br J Ophthalmol 2001 Darakhshanda et al reported 38% re-detachment rate Br J Ophthalmol 2001 after silicone oil removal.15 In another study, the report- Darakhshanda K et al15 Pak J Ophthalmol 2011 ed rate of re-detachment after silicone oil removal was 25.3%.16 Scholda et al reported 20.5% cases of retinal de- Khan B et al (Our study) Not published yet tachment in their study.17 In another study, conducted Ophthalmology Update Vol. 13. No. 2, April-June 2015 Recurrence of Retinal Detachment after Silicone Oil Removal by Zafar S et al, the rate of re-detachment after silicone Lucke K, Strobel B, Foerster M, Laqua H. Secondary glauco- oil removal was 20%.18 Pavlovic et al commented that ma after silicone oil surgery. Klin Monbl Augenheilkd 1990; eyes with completely attached retinas, the risk of com- Parrel JM. Silicone oil: physiochemical properties. In: Reti- plication and re-detachment after silicone oil removal is na. Volume 3. Edited by Glaser BM, Michels RG. St. Louis: CV relatively low.19 Mosby. 1989;261-77.
This was a retrospective study and the different Silicone study group. Vitrectomy with silicone oil or sulfur hexafluoride gas in eyes with severe proliferative vitreoretin- risk factors for re-detachment after removal of silicone opathy: Results of a randomized clinical trial- Silicone Study oil were not studied in detail due to lack of data. Fur- Report No 1. Arch Ophthalmol 1992; 110:770-9.
ther prospective studies with larger sample size and 10. Kampik A, Hoing C, Heidenkummer HP. Problems and timing in the removal of silicone oil. Retina 1992; 12(3):S11-6. longer follow up needs to be done to identify the risk 11. Azen SP, Scott IU, Flynn HW Jr, Lai MY, Topping TM, Benati L, factors for re-detachment.
et al. Silicone oil in the repair of complex retinal detachments. A prospective observational multicentre study. Ophthalmol- ogy 1998; 105(9):1587-97.
Re-detachment of the retina can occur after remov- 12. Lewis H, Burke JM, Abrams GN, Aaberg TM. Perisilicone pro- al of silicone oil in eyes having stable attached retina liferation after vitrectomy for proliferative vitreoretinopathy. after successful pars plana vitrectomy with silicone oil Ophthalmology 1988; 95:5583-91. tamponade. Detail assessment of the patient is impor- 13. Scholda C, Egger S, Lakits A, Walch K, von Eckardstein E, Biowski R. Retinal detachment after silicone oil removal. Acta tant to identify the eyes at risk of re-detachment.
Ophthalmol Scand 2000; 78:182-6.
14. Falkner CI, Binder S, Kruger A. Outcome after silicone oil re- 1O'Lenick AJ. Basic silicone chemistry: a review [Internet].1999. moval. Br J Ophthalmol 2001; 85:1324-7.
Available from: http://www.siliconespectator.com/articles/ 15. Darakhshanda K, Ghayoor I. Outcome of silicone oil removal in eyes undergoing 3-port pars plana vitrectomy. Pak J Oph- Cibis PA, Becker B, Okun E, Canaan S. The use of liquid silicone thalmol 2011; 27:17-20.
in retinal detachment surgery. Arch Opthalmol 1962; 68:590-9. 16. Jonas JB, Knorr HL, Rank RM, Budde WM. Retinal redetach- Stone W Jr. Alloplasty in surgery of the eye. N Engl J Med 1958; ment after removal of intraocular silicone oil tamponade. Br J Ophthalmol 2001; 85:1203-7.
McCuen BW, Landers MB, Machemer R. The use of silicon oil 17. Scholda C, Egger S, Lakits A, Haddad R. Silicone oil removal: following failed vitrectomy for retinal detachment with ad- results, risks and complications. Acta Ophthalmol Scand 1997; vanced proliferative vitreoretinopathy. Graefes Arch Clin Exp Ophthalmol 1986; 224(1);38-9.
18. Zafar S, Bokhari SA, Kamil Z, Shakir M, Rizvi SF and Memon Cians JD, Campbell WG. Vitrectomy techniques in the treat- GM. Outcomes of Silicone Oil Removal. JCPSP 2013; 23(7):476- ment of giant retinal tear: a flexible approach. Clin Exp Oph- thalmol 1988; 16:209-14.
19. Pavlovic S, Dick B, Schmidt KG, Tomic Z, Latinovic S. Long Nagpal M, Videkar R, Mehrotra N. Hybrid technique for sili- term outcome after silicone oil removal. Ophthalmology 1995; cone oil removal. Retina Today 2011; 36-40.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 CASE REPORT
Choroidal Melanoma in a Young Patient
Hussain Ahmad Khaqan FCPS, FRCS, FCPS (Vitreo Retina)1 Farrukh Jameel MBBS2, Hadia Jabeen MBBS3 Muhammad MBBS4, Usman Imtiaz MBBS5 Introduction: Choroidal melanoma is the most common primary malignant intraocular tumor and the second most common
type of primary malignant melanoma in the body.
Case Description:A 35-year-old male patient presented to our OPD with complaint of sudden painless decreased vision
for 4-5 months in left eye. Visual acuity was 6/6 OD and CF OS. There was a large mass supero-temporally just posterior to and indenting the crystalline lens. Fundus examination revealed large elevated amelanotic lesion superior to superior arcade and exudative retinal detachment inferiorly. Enucleation was done and the specimen was sent for histopathology.
Conclusion: Although the incidence of choroidal melanoma is highest around age of 55 years, it can present at an early
age and the index of suspicion should be high.
inferior exudative retinal detachment. MRI was done Choroidal melanoma is the most common primary to detect any extraocular extension. T1 weighted MRI malignant intraocular tumor in adults and the second scan revealed hyperintense mass arising from choroid most common type of primary malignant melanoma and involving the optic disc. There was no extraocular in the body(1). Primary choroidal melanoma arises from extension (Fig-5). Abdominal ultrasound didn't detect melanocytes within the choroid. Most choroidal mela- any metastasis and Chest X-Ray, CBC, LFT's and RFT's nomas are believed to develop from pre-existing mel- were normal too. Enucleation was done and the speci- anocytic nevi, though de novo growth of choroidal mela- men was sent for histopathology. nomas also occurs. A 35-year-old male patient presented to our OPD with complaint of sudden painless decreased vision for 4-5 months in left eye. Previous medical and surgical history was unremarkable. Patient was not on any kind of medication. There was no family history of any kind of tumor. Visual acuity was 6/6 OD and CF OS. Ocular examination revealed dilated tortuous episcleral ves- sels, sentinel vessels, (Fig-1) superotemporally. Cornea was clear and AC was quiet. There was a large mass superotemporally just posterior to and indenting the crystalline lens (Fig-2). Fundus examination revealed large elevated amelanotic lesion in the superior half (Fig-3) and exudative retinal detachment inferiorly. B- Scan showed a multilobular mass arising form the cho- roid with typical acoustic hollowness at the base and choroidal excavation (Fig-4). B-Scan also confirmed the 1Senior Registrar Ophthalmology, Lahore General Hospital / PGMI, Lahore. 2,3,4Residents in Ophthalmology, Lahore General Hospital / PGMI, Lahore. 5Resident Ophthalmology at Alshifa Trust Eye Hospi- tal, Rawalpindi Correspondence: Dr. Hussain Ahmad Khaqan, Department of Oph-
thalmology Lahore General Hospital / PGMI, Lahore. , Postal Address: House No.87, Eden
Canal Villas, Canal Bank Road, Thokar Niaz Baig, Lahore. Received: December 2014 Accepted: January 2015 Ophthalmology Update Vol. 13. No. 2, April-June 2015 Choroidal Melanoma in a Young Patient variable coloration, ranging from darkly pigmented to purely amelanotic. They typically are dome-shaped. As they enlarge, if they break through the Bruch mem- brane, they can assume a mushroom configuration. Other shapes found for these tumors are bilobular, multilobular, and diffuse. The last of these is charac- terized by lateral growth throughout the choroid with minimal elevation; it occurs in about 5% of cases. Treatment of primary choroidal melanoma with- out evidence of metastasis involves either globe- conserving therapy or enucleation. In a randomized clinical trial of patients with primary choroidal mela- noma treated with globe-conserving iodine-125 brachy- therapy versus enucleation, the Collaborative Ocular Melanoma Study (COMS) demonstrated no significant difference in mortality, 5, 10, and 12 years following treatment between brachytherapy and enucleation.5,6,7 Metastasis from uveal melanoma usually occurs within the first few years after enucleation. The liver is usually the first site of metastasis after treatment.8 There is some evidence to suggest that metastasis may occur several years before the diagnosis of hepatic metasta- sis is made.9 Other organs that may be affected include the lung, bone, skin, and central nervous system.10 The majority of patients with hepatic involvement succumb within a few months of detection of the metastatic le- Although the incidence of choroidal melanoma is highest around age of 55 years, it can present at an early age and the index of suspicion should be high.
Jack J Kanski BB. Clinical Ophthalmology: A systematic Ap- proach. 7th ed. Windsor: Elsevier; 2011.
Myron Yanoff JSD. Ophthalmology. 4th ed.: Elsevier; 2014.
Shields CL SJMJea. Uveal melanomas in teenagers and chil- dren: a report 40 cases. Ophthalmology. 1991;(98): p. 1662-6.
OA J. Malignant melanomas of the uvea in Denmark 1943– 1952: a clinical, histopathologic, and prognostic study. Acta Ophthalmol Suppl. 1963;(75): p. 17-78.
Diener-West M EJFSea. The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma. III. Initial mortal- ity findings. COMS report no. 18. Arch Ophthalmol. 2001;(119): Collaborative Ocular Melanoma Study Group. Ten-year fol- low-up of fellow eyes of patients enrolled in Collaborative Ocular Melanoma Study random- ized trials: COMS report no. Posterior uveal melanoma is an uncommon dis- 22. Ophthalmology. 2004;(111): p. 966-76.
The COMS randomized trial of iodine 125 brachytherapy for ease with an incidence of 5–6 cases per 1 million pop- choroidal mela- noma. V. Twelve-year mortality rates and ulation per year.2 It is usually diagnosed in the sixth prognostic factors. COMS report no. 28. Arch Ophthalmol. decade of life, and its incidence rises steeply with age.
2006;(123): p. 1684-93.
Gragoudas ES EKSJea. Survival of patients with metastases Uveal melanoma is rare in children.3 In most series, the from uveal melanoma. Ophthalmology. 1991;(98): p. 383-90.
median age at diagnosis is 55 years.4 In Jensen's series,4 Eskelin S PS, P S, al e. Tumor doubling times in metastatic ma- lignant melanoma of the uvea: tumor progression before and rates of disease decreased in males after age 69 years. It after treatment. Ophthalmology. 2000;(107): p. 1433-9.
is the most common primary intraocular malignancy, 10. Kath R HJBNae. Prognosis and treatment of disseminated and the leading primary intraocular disease, which uveal melanoma. Cancer. 1993;(72): p. 2219-23.
11. Rajpal S MRKC. Survival in metastatic ocular melanoma. Can- can be fatal in adults.2 Choroidal melanomas may have cer. 1983;(52): p. 334-6.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Frequency of High Glasgow Blatchford Score & its One Month Mortality in Patients presenting Frequency of High Glasgow Blatchford Score
& its One Month Mortality in Patients presenting
with Non-variceal Upper Gastrointestinal Bleeding
Imran Yahaya1, Waheedullah FCPS (Gastro)2, Jawad MBBS3 Muhammad Daud MBBS4, Muhammad Iltaf (FCPS)5 Objective: To determine the frequency of high Glasgow Blatchford scoring system and its one month mortality in patients
presenting with non variceal upper gastrointestinal bleeding. Patients with liver cirrhosis may develop upper gastrointestinal hemorrhage from a variety of lesions, which include those that arise by virtue of portal hypertension, namely gastro-esoph- ageal varices and portal hypertensive gastropathy and other lesions seen in the general population.
Study design: Descriptive case series.
Duration: The duration of study was six months after approval of synopsis.
Settings: Department of Gastroenterology and Hepatology Hayatabad Medical Complex Peshawar.
Material & Methods: This study was conducted at Gastroenterology and Hepatology Department, Hayatabad Medical
Complex, Peshawar. Duration of the study was six months in which a total of 140 at margin of error 5%, confidence interval 95% and 10%2 proportion of mortality among patients with high GB score at admission (non-variceal bleeding) using WHO sample size calculations.
Results: In this study 3% patients were in age range 20-30 years, 18% patients were in age range 31-40 years, 34%
patients were in age range 41-50 years, 35% patients were in age range 51-60 years,10% patients were above 60 years. Mean age was 30 years with SD ± 2.21. Fifty five percent patients were male and 45% patients were female. Twenty five percent patients had Glasgow Blatchford score < 12 and 75% patients had Glasgow Blatchford score more than 12. Mean Glasgow Blatchford score was 11 with SD ± 2.88. Among 140 patients mortality rate was 16%.
Conclusion: In conclusion, GBS is a scoring system that allows calculation of the scores using only clinical and laboratory
variables, without a need for endoscopy, and thereby, it can be easily used in the risk analysis of patients under emergency conditions. To support the results obtained from this study, future studies that contain more patients, are multi-centered, and that follow the patients after discharge from the ED are warranted.
Keywords: Glasgow Blatchford Scoring System, mortality, non variceal upper gastrointestinal bleed.
during the last 30 years, despite the introduction of en- Upper gastrointestinal bleeding (UGIB) is defined doscopic therapy that reduces the rate of rebleeding.1 as bleeding derived from a source proximal to the liga- Causes of non variceal upper GI bleeding include ment of Treitz and Bleeding from the upper GI tract is peptic ulcer, Mallory-weiss tear, erosive gastritis/du- approximately 4 times as common as bleeding from the odenitis, esophagitis/esophageal ulcer, malignancy, lower GI tract.1 Acute gastrointestinal hemorrhage is a angio-dysplasia/ vascular malformations and other common medical emergency. The mortality of patients causes having incidence of 20-50%, 15-20%, 10-15%, admitted to hospital for acute gastrointestinal bleeding 5-10%, 1-2%, 5% and 5% respectively.6,7 Currently, is about 10%, rising to more than 30% in patients who OGD is the standard investigation of choice for UGIB. bleed as inpatients.2 The incidence rates of UGIB dem- Endoscopic therapy has revolutionized the treatment onstrate a large geo graphic variation ranging from 48 of UGIB, with a recently greatly expanded therapeutic to 160 cases per 100,000 population, with consistent re- armamentarium.8 In the place where urgent esophago- ports of higher incidences among men and elderly peo- gastro-duodenoscopy (EGD) is unavailable, empirical ple.3,4 Patients with acute upper gastrointestinal (GI) pharmacological therapy with proton pump inhibitors bleeding commonly present with hematemesis and/or for non-variceal bleeding is recommended.9 Endoscopy melena.5 The mortality has decreased only minimally within 24 hours is recommended for most patients with acute UGI bleeding.10, 11 1,2,3,4 Medical Officers Gastro Unit 3Senior Registrar, Gastroenterology Unit, Hayatabad Medical Complex, Peshawar. The Blatchford score use only clinical and labora- tory data (before endoscopy) to identify patients who Correspondence: Dr. Waheed Ullah, FCPS., Medical Officer Gastro require intervention and predict future mortality. The Unit, Hayatabad Medical Complex, Peshawar. District Specialist, DHQ Hospital,Village & P.O. Samarbagh, District lower Dir, KPK. Blatchford score includes hemoglobin level, blood urea Cell: 0307 5040633 E-Mail: drwaheed2014@gmail.com level, pulse, systolic blood pressure, the presence of Received: Jan'2015 Accepted: Feb'2015 syncope or melena, urea, syncope and evidence of he- Ophthalmology Update Vol. 13. No. 2, April-June 2015 Frequency of High Glasgow Blatchford Score & its One Month Mortality in Patients presenting patic disease or cardiac failure and accurately identifies • Developed bleeding during hospital stay for some patients at low risk for clinical intervention like early other diagnosis.
endoscopy by using the Blatchford score.12,13,14,15 In one study, the frequency of High GBS was found to be 78- This study was conducted at Gastroenterology 84%2,16 and its 28 day mortality was reported to be up to Department Hayatabad Medical Complex, Peshawar in which a total of 140 patients were observed to de- This study is carried out to determine frequency termine the high Glasgow Blatchford scoring system of high Glasgow Blatchford scoring system and its and its one month mortality in patients presenting with one month mortality in patients presenting with non- non variceal upper gastrointestinal bleeding and the variceal UGIB so that we can categorize the patients in results were analyzed as age distribution among 140 high risk and low risk. GBS scoring system has been patients, was analyzed as 4(3%) patients were in age traditionally used for UGIB bleed in terms of need of ranging 20-30 years, 25 (18%) patients were in age rang- blood transfusion, intervention and mortality; it has ing 31-40 years, 48 (34%) patients were in age ranging very good value in categorizing the patients into low 41-50 years, 49 (35%) patients were in age ranging 51-60 risk and high risk.
years,14 (10%) patients were above 60 years. Mean age The results of this study will be compared with was 30 years with SD ± 2.21 (as shown in Table No 1) already available international data as the literature Gender distribution among 140 patients was analyzed suggested variable frequency of mortality of patients as 77(55%) patients were male and 63(45%) patients having high GBS scores, on the basis of results we can were female. (shown in Table No 2) Status of Glasgow draw conclusion and recommendations for future re- Blatchford score among 140 patients was analyzed as search work into it and also the same results will be 35(25%) patients had Glasgow Blatchford score < 12 shared with other health professionals and guidelines and 105(75%) patients had Glasgow Blatchford score and suggestions will be given for required changes in more than 12. Mean Glasgow Blatchford score was 11 routine management of patients of UGIB. This will help with SD ± 2.88 (as shown in Table No 3) Status of mor- our already compromised population with UGIB in re- tality among 140 patients was analyzed as mortality ducing the burden of morbidity related to it.
rate was 22(16%) while 118(84%) patients were normal. MATERIALS AND METHODS
(as shown in Table No 4) Settings: Department of Gastroenterology and Hepa-
Stratification of Glasgow Blatchford score with age dis- tology, Hayatabad Medical Complex, Peshawar.
tribution was analyzed as in 35cases of Glasgow Blatch- Study duration: Six months
ford score <12, 9 patients were in age range 31-40 years, Study Design: Descriptive case series.
11 patients were in age ranging 41-50 years, 12 patients Sample Size: Total sample size was 140 while taking
were in age ranging 51-60 years and 3 patients were margin of error 5%, confidence interval 95% and 10%2 more than 60 years. Where as in 105cases of Glasgow proportion of mortality among patients with high GB Blatchford score> 12, 4 patients were in age ranging score at admission (non- variceal bleeding) using WHO 20-30 years, 6 patients were in age ranging 31-40 years, sample size calculations.
37 patients were in age ranging 41-50 years, 37 patients Sampling technique: Consecutive, non probability were in age ranging 51-60 years and 11 patients were
sampling. The above mentioned conditions act as con- more than 60 years. (as shown in Table No 5) founders and if included will introduce bias in the Stratification of Glasgow Blatchford score with gender distribution was analyzed as in 35 cases of Glasgow Blatchford score <12, 20 patients were male and 15 patients were female. Where as in 105 cases of • Age more than 15 years.
Glasgow Blatchford score> 12, 57 patients were male • Upper gastrointestinal bleeding on initial assess- and 48 patients were female. (as shown in Table No 6) Stratification of mortality with age distribution was • Either gender.
analyzed as out of 22 cases of mortality 10 patients died in age range 51-60 years and 12 patients died in • Acute myocardial infarction, trauma, stroke and age ranging more than 60 years. (as shown in Table other conditions in association with upper gastro- No 7) Stratification of mortality with gender distribu- intestinal bleed.
tion was analyzed as out of 22 cases of mortality 13 • Variceal bleeding on endoscopy.
patients were male and 9 patients were female. (as • Cause not identified on endoscopy.
shown in Table No 8) Ophthalmology Update Vol. 13. No. 2, April-June 2015 Frequency of High Glasgow Blatchford Score & its One Month Mortality in Patients presenting Table No-1: age distribution (n=140)
Table No-8: stratification of mortality in
gender distribution (n=140)
Mortality
Upper gastrointestinal bleeding is one of the life Mean age was 30 years with SD ± 2.21 threatening complications in patients with liver cirrho- Table No-2: gender distribution (n=140)
sis. It is responsible for over 250 000–300 000 hospital admissions and $2.5 billion in costs in the USA each year.17,18 Upper gastrointestinal bleeding is from a source be- tween the pharynx and the ligament of Treitz, characterized by hemetemesis (vomiting up blood) and melena (tarry stool containing altered blood). Gastrointestinal endoscopy Table No-3: Glasgow Blatchford scoring findings (n=140)
remains the diagnostic and therapeutic procedure of choice for UGI bleeding. The epidemiology of various Glasgow Blatchford score
causes of upper G.I. bleeding has been changing in re- cent years.19,20 Variations in disease pattern from time to time require the need for periodic studies to define the changing etiological distribution for continuous medi- Mean Glasgow Blatchford Score was 11 with SD ± 2.88 cal education and learning. Risk scoring systems are Table No-4: mortality (n=140)
not used commonly in daily practice in the ED for the Mortality
patients with UGI system bleeding, and the patients are evaluated mostly based on the clinical decision of the emergency physician. However, in patients with UGI system bleeding, more objective criteria are warranted for deciding discharge/hospitalization of the patient, Table No-5: stratification of accuracy high Glasgow
the use of blood transfusion and the necessity of emer- Blatchford score in age distribution (n=140)
gent endoscopy. In this regard, as GBS scores may be calculated easily based only on clinical and laboratory 41-50 51-60 > 60
years years Total
variables, this system seems to be suitable for use in the In the retrospective study performed by Chen et al.21 in patients with non-variceal UGI system bleeding, GBS and Rockall scoring systems were compared, and Table No-6. stratification of accuracy high Glasgow
the sensitivity of the GBS system in the differentiation Blatchford score in gender distribution (n=140)
of high-risk patients for a cut-off value of GBS >0 was found to be higher (99.6%). Similarly, in our prospective study, which included the patients with non-variceal bleeding, the sensitivity of the GBS system was found to be high (100%) in the differentiation of high-risk pa- tients for a cut-off value of GBS >12. In our study, the Table No-7: stratification of mortality in
number of the subjects with UGI system bleeding with age distribution (n=140)
a GBS score ≤12 was 25% and, in this group of patients, none of the subjects that underwent endoscopy showed Mortality 20-30 31-40 41-50
years years
a serious pathology or required an intervention during the endoscopy. Thus, in our study, it was demonstrated that the patients with UGI system bleeding, who had a GBS score ≤12, did not require clinical and endoscopic intervention and could be safely discharged from the Ophthalmology Update Vol. 13. No. 2, April-June 2015 Frequency of High Glasgow Blatchford Score & its One Month Mortality in Patients presenting ED. While the retrospective study performed by Sriraj copy, and the enrollment of the patients to the follow- Askanthan et al.22 revealed a cut-off value of GBS ≤12 in up based only on their conclusions in the ED.
the differentiation of low-risk patients among the pa- In light of the data obtained from this study, we can state tients with UGI system bleeding, other studies23,24 used that the patients with UGI system bleeding who have GBS=0 in the differentiation of the low-risk patients.
a GBS score ≤3 may be safely discharged from the ED An ideal scoring system should have both a good and referred to the polyclinic to undergo an endoscopy. sensitivity and high specificity. However, in the stud- ies conducted, the sensitivity and specificity of the GBS In conclusion, GBS is a scoring system that allows system vary among high-risk patients with UGI system calculation of the scores using only clinical and labo- bleeding.25,26 In our study, the sensitivity and specificity ratory variables, without a need for endoscopy, and were 100% and 1.41% for a cut-off value of GBS >12, thereby, it can be easily used in the risk analysis of pa- 100% and 16.9% for a cut-off value of GBS >3, 96.63% tients under emergency conditions. To support the re- and 36.62% for a cut-off value of GBS >5, and 86.52% sults obtained from this study, future studies that con- and 69.01% for a cut-off value of GBS >8. In the study tain more patients, are multi-centered, and that follow performed by Chen et al.27 positive predictive value the patients after discharge from the ED are warranted.
(PPV) and negative predictive value (NPV) for GBS REFERENCES
>0 were 75.2% and 96.4%, respectively. In the study Mitchell S. Cappell, Friedel D. Initial management of acute up- conducted by Farooq et al.
per gastrointestinal bleeding: from initial evaluation to gastro- 28 PPV and NPV were 37% intestinal endoscopy. Med Clin N Am 2008:491-509.
and 100%, respectively for GBS >0 and 42% and 82% Ferguson CB, Mitchall MB. Non-variceal upper gastrointestinal for GBS >5. In our study, PPV and NPV were 56% and bleeding. Ulster Med J 2006;75:32-9.
100% for GBS >0 and 65.6% and 89.7% for GBS >5, re- Manguso F, Riccio E, Bennato R, Picascia S, Fiorito R, Martino R et al. In-hospital mortality in non-variceal upper gastrointes- spectively. In our study the mortality rate was 16% and tinal bleeding Forrest I patients. Scandinavian J Gastroentol the those patients were more than 50 year of age similar results were found in other studies in which the mortal- Thomas F, Imperiale, Jason A, Dominitz, Dawn T, Provenzale et al. Predicting poor outcome from acute upper gastrointesti- ity rate was 11% and 13%,29,30 nal hemorrhage. Arch Inter Med 2007;167:1291-6.
In the study performed by Hsu et al.29 in cirrhotic Celinski K, Cichoz-Lach H, Madro A, M. Slomka M, Kasztelan- patients with UGI system bleeding, six prognostic fac- Szczerbinska B, T.Dworzanski T. Non-variceal upper gastroin- tors were determined: male gender, hepatocellular testinal bleeding guidelines on management. J Physiol Pharma- col 2008;59:215-29.
carcinoma, non-hepatocellular carcinoma, hypoxemia, Van leerdam ME. Epidemiology of acute upper gastrointestinal serum bilirubin level, and PT. The investigators re- bleeding. Best Pract Res Clin Gastrointerol 2008:22:209-24.
ported that these six clinical parameters might be easily Bardou M. Management of acute non-variceal upper gastroin- testinal bleed. Indian J Gastroenterol 2006;25:22-4.
obtained in the ED and be valuable in the early risk de- Talafeeh A, Eweis S, Holy M. Endoscopic finding in upper termination in cirrhotic patients with acute UGI system gastrointestinal bleeding patients at Prince Hashim Hospital. J bleeding. For the model used in the aforementioned Rawal Med Sci 2004;1:71-3.
Adam T, Javed F, Khan S. Upper gastrointestinal bleeding: An study, the sensitivity was 22.73% and the specificity etiological study of 552 cases. J Pak Inst Med Sci 2004;15:845-8.
was 99.8%. In our study, which did not enroll only cir- 10. Chaudhry AW, Tabassum HM, Chaudhry MA. Pattern of up- rhotic patients with UGI system bleeding, but instead per gastrointestinal bleeding at Rahim Yar Khan. Ann King Ed- all patients with UGI system bleeding and in whom the ward med Coll 2005;11:282-3. 11. Selinger CP, Ang YS. Gastric antral vascular ectesia (GAVE): GBS system was used, the sensitivity and the specificity an update on clinical presentation, pathophysiology and treat- were 86.52% and 69.0%, respectively, for GBS>8, and ment. Digestion 2008;77:131-7.
thereby, GBS seemed more sensitive.31 12. Stojakov D, Velickovic D, Sabljak P, Bjelovic M, Ebrahimi K, Spica B et al. Diciulafoy's lesion: rare cause of massive upper Although in the literature, there has been no consen- gastrointestinal bleeding. Acta Chirr Lugosol 2007;54:125-9.
sus on the best scoring system in various studies per- 13. John G Lee. What is the value of early endoscopy in upper gas- formed using the Rockall scoring system and/or the trointestinal bleeding? Nat Clin Pract Gastroenterol hepatol GBS system,19 the GBS system seems to be more use- 14. Donner MW, Bosma JF, Robertson DL. Anatomy and physiolo- ful, especially in patients with non-variceal UGI system gy of the pharynx. Gastrointest Radiol 1985;10:196.
bleeding. In our study, which included all the patients 15. Ekberg O, Lindstrom C.The upper esophageal sphincter area. with non-variceal UGI system bleeding, we used the Acta Radiol 1987;28:173.
16. Boyce H. Endoscopic definitions of esophagogastric junction GBS system, and found it useful in the differentiation of regional anatomy. Gastrointest Endosc 2000;51:586.
high-risk patients. The limitations of this study include 17. Kim T, Shijo H, Kokawa H. Risk factors for hemorrhage from the single centered design, small number of patients, gastric fundal varices. J Hepatol 1997;25:307-12 18. Toyonaga A, Iwao T. Portal hypertensive gastropathy. J Gas- the fact that all the patients did not undergo an endos- troenterol Hepatol 1998;13:865–77.
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Frequency of High Glasgow Blatchford Score & its One Month Mortality in Patients presenting 19. Primignani M, Carpinelli L, Preatoni P. Natural history of por- useful scoring system for detecting patients with upper gastro- tal hypertensive gastropathy in patients with liver cirrhosis.
intestinal bleeding who do not need endoscopic intervention. J The new Italian endoscopic club for the study and treatment Gastroenterol Hepatol 2007;22:1404-8.
of esophageal varices (NIEC). J Gastroenterol 2000;119:181-7.
26. Chen IC, Hung MS, Chiu TF. Risk scoring systems to predict 20. Beck PL, McKnight W, Lee SS. Prostaglandin modulation of the need for clinical intervention for patients with nonvariceal gastric vasculature and mucosal integrity in cirrhotic rats. Am upper gastrointestinal tract bleeding. Am J Emerg Med 2007; J Physiol 1993;265:453-8.
21. Nasir N, Nadeem MA, Imran M, Hussain I, Chaudhry NU. Oe- 27. Farooq FT, Lee MH, Das A. Clinical triage decision vs risk sophageal varices Vs peptic ulcer: A Study of 100 Patients Pre- scores in predicting the need for endotherapy in upper gastro- senting in Mayo Hospital with Upper Gastrointestinal Bleed- intestinal bleeding. Am J Emerg Med 2012;30:12934.
ing. Pak J Gastroenterol 1998; 2:0-.
28. Hsu YC, Liou JM, Chung CS. Early risk stratification with sim- 22. Shahin WA, Abdel-Baset EZ, Nassar AK, Atta MM, Kabil SM, ple clinical parameters for cirrhotic patients with acute upper Murray JA, Low incidence of Helicobacter pylori infection in gastrointestinal bleeding. Am J Emerg Med 2010;28:884-90.
patients with duodenal ulcer and chronic liver disease. Scand J 29. Gralnek IM, Dulai GS. Incremental value of upper endoscopy for triage of patients with acute non-variceal upper-GI bleed- 23. Gravante G, Delogue D, Vanditti D. Upper and lower gastro- ing. Gastrointest Endosc 2004;60:9-14.
intestinal diseases in liver transplant candidates. Int J 30. Pang SH, Ching JY, Lau JY. Comparing the Blatchford and pre- Colorectal Dis 2008;32:201-6 endoscopic Rockall score in predicting the need for endoscopic 24. Srirajaskanthan R, Conn R, Bulwer C, Irving P. The Glasgow therapy in patients with upper GI bleeding. Gastrointest En- Blatchford scoring system enables accurate risk stratification of patients with upper gastrointestinal haemorrhage. Int J Clin 31. Tham TC, James C, Kelly M. Predicting outcome of acute non- variceal upper gastrointestinal haemorrhage without endos- 25. Masaoka T, Suzuki H, Hori S. Blatchford scoring system is a copy using the Rockall Score. Postgrad Med J 2006;82:757-9.
Where all Ophthalmologists Join to: DICOVER NEW IDEAS
LATEST TRENDS & HOTTEST TOPICS
PARTICIPATE AT One Place:
where experts and thought leaders shape our profession BE ENERGIZED & GET INSPIRED
From: OPHTHALMOLGY UPDATE
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Meatal Mobilization Technique for
Childhood Hypospadias Repair, an Early
Experience at Lady Reading Hospital, Peshawar
Muhammad Ayub Khan, FCPS (Paeds Surgery)1 Muhammad Uzair FCPS (Paeds Surgery)2, Munir Ahmad FCPS3 Younas Khan FCPS (Paeds Surgery)4, Arshad Kamal FCPS (Paeds Surgery)5 Muhammad Fayaz MBBS6, Mussarat Hussain FCPS7, Asif Ahmad MBBS8 Objective: To determine the effectiveness of meatal mobilization (MEMO) by distal urethral preparation as an improved
surgical technique for distal hypospadias repair, including glanular, coronal and subcoronal location of the meatus, with or without chordee in children.
Material and Methods: A total number of 60 patients with distal penile hypospadias with or without chordee were operated
by using MEMO hypospadias repair technique from April 2013 to April 2014. After penile degloving, mobility of the meatus is evaluated and after urethral preparation the meatus is fixed to the tip of the glans. Glanuloplasty covers the neo-urethra providing a barrier layer. Shaft skin reconstruction completes the procedure Patients were evaluated regarding operative time, peri- or postoperative complications, hospital stay as well as functional and cosmetic outcome.
Results: Mean duration of surgery was 43 minutes. There was no repair breakdown, new-onset chordee, or meatal steno-
sis. Primary success rate was 95%. Three patients developed urethral fistula which responded well with short regimen of weekly meatal dilatation for 4 weeks. preputial edema occurred in 3 in non-circumcised patients. In one patient a mild ventral penile deviation without a need for correction was noted leaving a success rate of 96%.
Conclusion: The MEMO-technique is a valid and reliable method for the correction of distal hypospadias.This method
istechnically simple, less time consuming giving the best cosmetic results with least complications.
Key Words: Hypospadias ,Meatal Mobilization, Urethral Reconstruction.
bines meatal mobilization by distal urethral dissection Distal Hypospadias accounts for 50-60% of all with steps of previously established techniques, e.g. a forms of hypospadias. with an increasing incidence be- rotational flap for fashioning the Firlit preputial collar ing present in 1 out of 125 male newborns Of those, 15% and straight-forward glanuloplasty.4,5 The aim of this are glanular, 50% coronal, 30% subcoronal,and 5% are study was to determine the short term results of memo of the megameatus intact prepuce (MIP) variant.1 The hypospadias repair for distal penile hypospadias in goal of modern hypospadias repair is to achieve func- tionally as well as cosmetically normal looking glans, Objective: To determine the effectiveness of meatal mo-
meatus and phallus.2 Generally, the surgical technique bilization (MEMO) by distal urethral preparation as an of choice is decided upon meatal location, the appear- improved surgical technique for distal hypospadias re- ance of the meatus relative to the glans, the presence pair, including glanular, coronal and subcoronal loca- or absence of chordee, and the quality of the preputial tion of the meatus, with or without chordee in children.
hood. the meatal mobilization (MEMO) technique was MATERIALS AND METHODS
developed to correct coronal and subcoronal hypospa- This descriptive study was conducted in the pae- dias. According to the technique of the meatus mobi- diatric surgery unit, Lady Reading Hospital, Pesha- lization, this operation Method referred to as MEMO, war over a period of eight months from June 2009 to based on the work by Beck 1898.3 This approach com- February 2010. Non probability sampling techniques was used. Children between 2 and 14 years, with dis- Associate Professor, Paeds Surgery, 2Medical Officer, Paeds Surgery unit Govt. PGMI LRH Peshawar. 3Senior Registrar Surgical C unit, tal penile hypospadias with or without chordee were Khyber Teaching Hospital, Peshawar. 4Assistant Professor, Paeds included and those who had proximal hypospadias Surgery, 5Senior Registrar, Paeds Surgery, 6Junior Registrar, Paeds Surgery, 7Medical Officer, Paeds Surgery, 8Resident Paeds surgery, i.e midshaft penoscrotal and perineal hypospadias Postgraduate Medical Institute, Lady Reading Hospital Peshawar- were excluded from the study .All those patients ful- filling inclusion criteria of this study whose parents Correspondence: Dr. Muhammad Ayub Khan, FCPS(Paeds Surgery) gave informed consent after explanation of the whole Associate Professor, Paeds Surgery, PGMI LRH Peshawar. Cell: 0300-5979070, E-mail: akpsurgeon63@gmail.com protocol, benefits versus risks of surgery were admit- ted through the outpatient department of the hospital. Received: January 2015 Accepted February 2015 Each patient was thoroughly re-examined by by taking Ophthalmology Update Vol. 13. No. 2, April-June 2015 Meatal Mobilization Technique forChildhood Hypospadias Repair, an EarlyExperience at Lady Reading Hospital, Peshawar history, complete clinical examination routine investi- sion 16. Age of patient and the time taken for operative gation i.e., Haemoglobin, urine R/E, HBs Ag, anti HCV procedure was analyzed for mean and standard devia- antibodies and other relevant investigation if necessary tion any complication were expressed in frequencies were also done All patients were operated under gen- and percentages data.
eral anesthesia. A tourniquet was applied to maintain a bloodless field and a 3/0 prolene stay suture taken A total of 60 patients with distal penile hypospa- into glans for traction and later to secure the urethral dias were analyzed for age, operative time and post- stent An intra-urethral Stent is inserted and skin inci- operative complications. All these patients were in the sion is performed in a cicumurethral fashion.The initial age range from 2 to 10 years. Mean age was calculated dissection of the penile skin is started dorsally along 3.9 years ± SD 1.86. Mean operative time was 47 min- Buck s fascia until the base of the penis is reached. The utes (33-56 minutes). Mean duration of hospitalization key step of the procedure is assessment of distal ure- was1.5 days (1 to 3 days). There were no complications thral mobility after penile skin dissection. Only with an during surgery in any of the patients. The overall rate appropriately mobile urethra the MEMO technique can of urethra-cutaneous fistula was 5% (3 in 60 patients) be performed. The meatus is incised circumferentially two of these patients were treated successfully with starting laterally on both sides of the meatus. The cor- weakly meatal dilation under topical xylocaine anes- poral bodies represent the dorsal plane of mobilization. thesia for four weeks remaining one patient underwent Along this plane dissection is easy and is performed 1 for successful surgical correction of fistula repair after to 1.5 cm proximally (Fig. 1-4). The length of mobili- 6 months. three patients had a minor complication of zation depends upon the mobility of the urethra, but preputial edema in which circumcision was not per- dissection should not be done too far proximally avoid- formed all of these patients were treated conservative- ing curvature and fistula formation. Following mobi- ly by dressing, two patients had local hematoma, which lization the meatus is easily brought up to the tip of was treated conservatively by compressive dressing; the glans. Incision of the glans up to the tip is followed one of the patient noted a split urinary stream which by excision of excess mucosa on both sides. Dissec- was improved by topical application of petroleum jelly.
tion of glanular wings allows tension free rotation of Cosmetic appearance of the glans, meatus and phallus glanular tissue to cover the underlying urethra . Using were acceptable.
6-0 vicryl interrupted sutures adaptation of glanular und urethral epithelium is performed. Glanuloplasty The MEMO technique, based on a procedure first is accomplished with two or three 6-0 vicryl sutures. described by Beck , allows for correction of most coro- It brings spongy tissue ventrally covering the urethra nal and subcoronal hypospadias without tubularizing while a conic glans is constructed. Circumcision was the urethra or applying a some flap procedure.1,3 Utili- performed. Sterile dressing was performed around the zation of this procedure was not consistently successful penis and remains in place overnight. Patients were fol- because of the high incidence of postoperative chordee lowed for three months. with their first visit commenc- due to inadequate mobilization of the urethra.6 Nu- ing at the 7th day postoperatively for the removal of the merous ingenious methods for urethral advancement stent in out patients department. The next visits were were reported by many authors.7,8 The ventral aspect scheduled on 1st and 3rd months in the outpatient de- of the urethra should not be too flimsy and the urethra partment All patients were followed for any complica- should be mobile enough for this procedure. This ma- tion and documented in a predesigned proforma for neuver additionally creates a cosmetically appealing each patient. All data was analyzed by using SSPS ver- conical shape of the glans.1 Diagrammatic representation of MEMO-technique
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Meatal Mobilization Technique forChildhood Hypospadias Repair, an EarlyExperience at Lady Reading Hospital, Peshawar The fact that more than 300 different operations distal hypospadias, and the successful repair of distal are described in the literature reflects the wide spec- hypospadias can be easilly achieved by meatal mobili- trum of the anomaly, and proves that the treatment zation technique which is a single stage procedure hav- has not been perfected.6 In the presented study, 60 boys ing low complication rate,good cosmetic results and is underwent surgery using the MEMO technique. No technically simple to learn.
urethral stricture noted in all operated patients, three patients developed urethrocutaneuous fistula, two of Seibold J, Amend B, Saladin , Alloussi H S, Colleselli D, Tode hoefer T, Gakis G, Merseburger A, Sievert DK, Stenzl these patients responded well with weakly meatal dila- A, Schwentner C. Meatal mobilization (MEMO) technique for tation under topical anesthesia and hence not requir- distal hypospadias repair: Technique, results and long-term ing any major surgical correction, the remaining one follow-up. CEJU March 2010; 63 :125-28.
Uzair M, Ahmad M, Hussain M, Younus M, Khan K. Frequen- patient was subjected to successful operative repair of cy of urethrocutaneous fistula following snodgrass hypospa- fistula after failure of conservative management after 6 dias repair in children. JPMI 2013; 27(1):74-77.
months of initial repair. Beck C. A new operation for balanic hypospadias. NY Med J jan 1898; 29: 147-148.
Overall rate of urethra-cutaneous fistula post Seibold J, Boehmer A, Verger A et al. The meatal mobilization MEMO repair was 5% in our series compared to Sei- technique for coronal/subcoronal hypospadias repair. BJU Int bold etal who reported a fistula rate of 1% .1 This high 2007; 100: 164-167.
Redman JF. A favorable experience with rotational flap tech- rate of urethra-cutaneous fistula post MEMO repair in niques for fashioning the Firlit preputial collar. J Urol 2006; 176: our series compared to Western studies might be the early learning curve of authors ,as a thorough literature Elemen L, Tugay M. Limited Urethral Mobilization Technique in Distal Hypospadias Repair with Satisfactory Results, Balkan search was made to compare our results with the local Med J 2012; 29: 21-5 studies.No satisfactory local studies were available to Hamdy H, Awadhi MA, Rasromani KH. Urethral mobilization compare our results with local results.
andmeatal advancement: a surgical principle in hypospadias repair.Pediatr Surg Int 1999;15:240-2.
CONCLUSION
Atala A. Urethral mobilization and advancement for midshaft Over 80 percent of boys with this condition have todistal hypospadias. J Urol 2002;168:1738-41.
Ophthalmological Society of Pakistan, KPK Branch
is holding the next Ophthalmic Symposium at From 7-9 August 2015 Dr. Mir Ali Shah, Associate Professor Department of Ophthalmology, Lady Reading Hospital, Peshawar.
Cell : 03005948091, Email: drmashahpsh@gmail.com Ophthalmology Update Vol. 13. No. 2, April-June 2015 َن ﻮُﻌ ِﺟا َ ِﻪﻴَﻟِا ﺎَِا َو ِ ِﷲ ﺎَِا َن ﻮُﻌ ِﺟا َ ِﻪﻴَﻟِا ﺎَِا َو ِ ِﷲ ﺎَ Forever Loved - Forever Missed
Prof. M. Naseem Ullah Prof. M. Afzal Farooqi Principals of Rawalpindi Medical College
Recently, the death of Prof. M. Naseem Ullah Urology. He is well known in the medical frater- and Prof. M. Afzal Farooqi, both Principals of Raw- nity as the best surgeon in the twin cities. With alpindi Medical College, was widely mourned in his death the college is deprived of his guidance the twin city of Islamabad and Rawalpindi, espe- and support . He was bestowed with a high sense cially by the medical community at the large. They of honor and integrity for the collective goal of our were the teachers of teachers and great mentors in their respective fields. Hundreds of students, doc- The editorial board and the management of tors, professors and representatives of Governmen- Ophthalmology Update, bring on record the ser-
tal and pharmaceutical institutions attended the fu- vices of these professors who were responsible for neral. They earned fame through their professional the development and progress of the college in its skill and commitment.
formative years. We announce the untimely de-
Prof. M. Naseem Ullah served as Professor of mise of our highly revered professors, impeccable Medicine, he had a special interest in academic and teachers and charismatic personalities with pro- research work. After retirement he joined Islama- found grief and sorrow. Both the professors were bad Medical & Dental college as Prof. of Medicine embodiment of simplicity and role model of medi- & Dean of the faculty. His contributions to the pro- cal education. May All bless their souls in peace fession will be ever remembered Prof. M. Afzal Farooqi served as Professor of Chief Editor Ophthalmology Update Vol. 13. No. 2, April-June 2015 The Queen of Mountains - A Shining Pearl of Pakistan
It is not only a hill station but also a tourist para- dise. It is a true example of natural beauty. The mind and soul refreshes when you see the green beauty cov- ered with clouds all around you. The lush green lawns, the beautiful rain drops, the colorful flowers, the scenic beauty and happy faces will surely give you strength.
The Murree Hills, 55 kilometers from Islamabad, at an altitude of 2286 m is the most popular resort in Pakistan. With a perfect Himalayan atmosphere and equipped with all modern facilities like good commu- nication network, resort hotels, golf course and chair- lift/cable cars. Murree and Gallies are a wonderful re- treat from the hot weather of the plains in summer.
After snow fall at the Hills
Speculations abound on how Murree got its name, er near the monument and in 1917 Captain Richardson some scholars (according to Virgil Miedema, published passed an order to demolish the tomb in order to keep in his book: ‘Murree - A glimpse through the Forest'
the pilgrims away. There were protests and the demoli- published by Maple-Books, New Deihi in 2002, and tion was stopped. In 1950 the tomb was rebuilt but the the excerpts carried on by Mr. Ansar Saleem in an watch tower was removed. Today, there is television English Daily ‘DAWN' in 2014 from pages 13-18 high- transmitter looming over the tomb.
lighted on the topic "Pages from the History") say that More prosaic explanations for the names abound the name is a corruption of the word Mary or Mariam as well. Murree is a Turkish word meaning "pasture". It who died at the age of 70 and buried in a tomb at Pindi may come from the Urdu or Arabic, meaning an abode Point. According to Mr. Abdul Latif, Chief officer of the or a place, like in Shalimar, a place of happiness, it may Municipal Committee, Murree skeptically said at the come from the English word "Merry" from an English time of centenary celebrations of Murree in 1967 that Officer Mr. Murray, or from "Murreey" after the purple Mary roamed thousand years ago in the thick forests of or mulberry-colored mountains. In Hindi and the local Murree en route to Kashmir. In fact there is an evidence dialect Marhi means a high place, this Marhi being the in the records of Municipal committee of a dispute over original grazing ground for the villages of Mooseearee the alleged tomb. In 1858 the British built a watch tow- raised in 1826, Mohra Sharif, Dewal Sharif and Aliot.
Lying on the outskirts of the Himalaya, the Mur- ree Ridge was officially identified as a potential site for development of a hill station by Edward Thornton, the Commissioner of Jhelum Division. A detailed survey of the Ridge, its climate, temperature, rainfall, flora and fauna, tribes and their customs, water resources, etc. were carefully and quickly undertaken. Located at 33° 54' 30" north latitude and 73° 26' 30" east longitude. it was soon confirmed that it was indeed a most suitable place for a sanatorium. In 1850, the Murree Tahsil was transferred from Hazara District to Rawalpindi Dis- trict, thereby facilitating its development as a military cantonment. The scenery upon the wooded side of the Murree ridge is not surpassed in any of the Punjab hill stations and the climate of Murree is said to be well adapted to the British climate.
Sunset at Murree Hills
Ophthalmology Update Vol. 13. No. 2, April-June 2015 Murree: The Queen of Mountains - A Shining Pearl of Pakistan In March of 1849, the British decided to establish for the Administration of Murree Town" were framed Murree as a sanatorium. In 1851, Murree was selected in 1851, which allowed for a Murree Sanatorium Com- as the summer headquarters of Punjab. The Mall was mittee to be established at Saumly. A total reduction established in 1850, is the centre of shopping area, in land revenue of Rs.114.40 and cash compensation of where most people congregate. Good buys in Murree Rs.1,935 was proposed for Ilyot and Mooseeareeareas
are Kashmiri shawls, furs, walking sticks, fruits and and adjoining areas. This was approved by the Chief nuts. Murree's pistachio nuts are reputed to be the best Commissioner of the Punjab. A special grant was pro- in Pakistan.
posed in the form of a cash lease payment of Rs.50 per The Imperial summer capital was popularized by annum in perpetuity. Upon the conclusion of protracted Rudyard Kipling- a noble laureate from Lahore and negotiations with the villagers, the proposal went to Chief Editor of an English daily "Civil & Military Ga- Calcutta for final approval. Finally, this annual payment zette an English Daily" being published from Lahore. was approved by the Governor-General, Lord Dalhou- Dane Kennedy commented: ‘Located on peaks that sie, by an order dated November 23, 1855. The story goes loom like sentinels over heat-shimmering plains. Mur- that the original bargain with the people of that area was ree remains among the most curious monuments to the actually for Rs.60 per annum as lease payment, instead British colonial presence in the area. The Saumly Sana- of Rs.50. Since the Maim Sahiba (Lord Dalhousie's wife)
torium was primarily established for the European in- being a British national, was poorly attired according to valids, but hill stations soon assumed an importance the Muslim customs of the area, the villagers offered that far exceeded the therapeutic attraction. To these Rs. 10/- for the purchase of Shalwar, Kameez and a
cloud-enshrouded sanctuaries the British expatriate shawl for the Maim Sahiba to dress her properly.
elite but also to familiarize with the alien culture with By 1850, more than 50 bungalows had been con- the locals living in areas like Aliot, a village 2 kilom-
structed towards Kashmir Point, Pindi Point and along eter down the Bhurban. Here they established political Kuldannah Road. In 1851, troops were first quartered headquarters and military cantonments and centers in Murree, and permanent barracks were erected in where from they issued executive orders. 1853. Holy Trinity Church on the Mall (Jinnah Road) In 1845 Murree was brought under the control of was opened on May 17, 1857., and the first Sunday East India Company rule and after the Treaty of Lahore Mass service was served.
(March 9, 1846), the first resident in the Punjab was Henry Lawrence, later founder of the famous Lawrence
1. Mr. Salim Ansar ‘Pages from the history', The News, Lahore. Mr. Arshad Mahmood Abbasi, former: Nazim of Union Coun- schools in Ghora Gali (Murree), Abbotabad & Law- rence gardens in Lahore came to Murree. The "Rules Murree — A Glimpse Through the Forest by Virgil Miedema Ophthalmology Update Vol. 13. No. 2, April-June 2015 Instructions to the authors Instructions to the Authors
All materials submitted for publication should be Abstract: Abstract of original article should be in sent to the journal ‘Ophthalmology Update'. Articles/ structured format with the following sub-headings: research papers which have already been published Objective, Design, Place and duration of Study, Patients or accepted elsewhere for publication should not be & Methods, Result and Conclusion.
submitted. A paper that has been presented at a scientific Introduction:
This should include the purpose of meeting, if not published in full in proceeding or similar the article. The rationale for the study or observation publication may be submitted. Press reports of meetings should be summarized.
will not be considered as breach of this rule.
Methods: Study design and sampling methods
Ethical Aspects: If articles, tables, illustrations or should be mentioned. The selection of the observational
photographs, which have already been published, are or experimental subjects (patients or experimental included, a letter of permission for republication (or its animals, including controls) should be described clearly. excerpts) should be obtained from the author(s) as well as The methods and the apparatus used should be identified the editor of the journal where it was previously published. and procedures described in sufficient details to allow Material for Publication: The material submitted other workers to reproduce the results and references
for publication may be in the form of original research, a to established methods. All drugs and chemicals used review article, short communications, a case report, recent should be identified precisely, including generic names, advances, new techniques, review on clinical/medical/ doses, routes of administration.
ophthalmic education, a letter to the editor, medical quiz, Results: These should be presented in a logical
Ophthalmic highlights/update, news and views related sequence in the text, tables and illustrations. Only to the field of medical sciences. Editorials are written by important observations should be emphasized or invitation. Report on Ophthalmic obituaries should be summarized.
concise. Author should keep one copy of the manuscript Discussion: The author's comments on the result,
for reference, and send three copies (laser or inkjet) to supported with contemporary references, including the Managing Editor, Ophthalmology Update through arguments and analysis of identical work done by others. E-mail/CD or by post in MS word. Photocopies are not Brief acknowledgement may be made at the end.
accepted. Any illustrations or photographs should also Conclusion: Conclusion should be provided under be sent in duplicate. Authors from outside Pakistan can separate heading and highlighting new aspects arising also e-mail their manuscript. It should include a title from the study. It should be in accordance with the page, E-mail address, fax and phone numbers of the study.
corresponding author. There should be no more than 40 Copyright: Material printed in this journal is the
references in an original/review article. If prepared on copyright of the publisher of Ophthalmic Newsnet/ computer, a CD should be sent with the manuscript.
Ophthalmology Update and may not be reproduced Dissertation/Thesis Based Article: An article based
without the permission of the editor/publisher. on dissertation submitted as part of the requirement The publisher only accepts the original material for for a Fellowship can be sent for publication after it has publication with the understanding that except for been approved by the relevant institution. Dissertation abstracts, no part of the data has yet been published based article should be re-written in accordance with the or will be submitted for publication elsewhere before instructions to authors.
appearing in the journal. The Editorial Board makes References: References should be numbered in every effort to ensure the accuracy and authenticity of
the order in which they are called in the text. At the the material printed in the journal. However, conclusions end of the article, the full list of references should give and statements expressed are the views of the authors the names and initials of all authors in Vancouver style and do not necessarily reflect the opinions of the based on the format used by the NLM in Index Medicus. Editorial Board. Publishing of advertising material does It verify the references against the original documents not imply an endorsement by the Ophthlmic Newsnet / before submitting the article.
Peer Review: Every paper will be read by at least
Address for Correspondence: The Chief Editor,
two staff editors of the editorial board. The paper selected Ophthalmology Update, 267-A, St: 53, F-10/4, Islamabad, will then be sent to one or more external viewers.
Ophthalmology Update Vol. 13. No. 2, April-June 2015

Source: http://prime.edu.pk/ophthalmology/2015/apr_jun_2015.pdf

Sa pathology newsletter

Reference interval changes 2 Significance of ANCA 4 Type 1 diabetes 6 INSIDe Clinical Utility of Bone Turnover Markers 8 Ulysses Syndrome – is it the liver? 10 Test ordering standardisation 11 Order of Draw Quick Guide 12 HbA1cFor our patients and our population transport improvement, will enable us to Complement method change From the Executive Director meet future challenges and maintain

neurohumanitiestudies.eu

Neuroaesthetics: A Coming of Age Story ■ Neuroaesthetics is gaining momentum. At this early junc- gence of experimental neuroaesthetics. I then suggest a few areas ture, it is worth taking stock of where the field is and what lies within neuroaesthetics that might be pursued profitably. Finally, I ahead. Here, I review writings that fall under the rubric of neuro- raise some challenges for the field. These challenges are not