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Contents
„„ EDITORIAL
ƒƒ
Meibomian Gland Dysfunction (MGD)
Sameera Irfan -------------------------------------------------------------------------------------------------------------------------------------- 49
„„ OPHTHALMIC SECTION / ORIGINAL ARTICLES
ƒƒ Neuro-imaging Patterns of Isolated Ocular Motor Nerve Palsies in a Pakistani Cohort
Tayyaba Gul Malik et al ------------------------------------------------------------------------------------------------------------------------------ 52
ƒƒ
A Study of Prevalence of Risk Factors in Patients with NonArteriticAnterior Ischemic Optic Neuropathy (Na- Aion)
ƒƒ
Dacryocystorhinostomy - is Endonasal Endoscopic Approach A Viable Option?
ƒƒ
Ocular and systemic Complications of Intravitreal Bevacizumab (Avastin) therapy
ƒƒ
Incidence of Intraocular Foreign Body in Penetrating Trauma presented to a
Tertiary Care Hospital of Khyber Pakhtun Khwa and its Visual Outcome
Khawaja Khalid Shoaib et al ------------------------------------------------------------------------------------------------------------------------ 59
Akhunzada Muhammad Aftab et al --------------------------------------------------------------------------------------------------------------- 62
Mohammad Idris et al -------------------------------------------------------------------------------------------------------------------------------- 66
ƒƒ
To Determine the Efficacy of Tattoo Ink in Changing the Color of Rabbit’s Iris
ƒƒ
Incidence of Hepatitis B & C among Admitted Eye Patients in Tertiary Care Hospital of Peshawar
ƒƒ
Visual Outcome & Complications of Scleral-fixation Posterior Chamber Intraocular Lenses
ƒƒ
Prevalence and Density of Amblyopia in Strabismic Patients of School Age Children
ƒƒ
Tuberous Sclerosis Complex
ƒƒ
Association of Anemia with Diabetic Retinopathy in Patients with Type II Diabtese Mellitus
ƒƒ
Intraocular Pressure Control after Cataract Extraction with Posterior Chamber
Intraocular Lens Implantation in Phacomorphic Glaucoma
ii
Akhunzada Muhammad Aftab et al --------------------------------------------------------------------------------------------------------------- 56
Mehdi Soltanifar et al -------------------------------------------------------------------------------------------------------------------------------- 69
Bilal Bashir et al --------------------------------------------------------------------------------------------------------------------------------------- 72
Mir Ali Shah Aftab et al ---------------------------------------------------------------------------------------------------------------------------- 75
Mohammad Alam et al ------------------------------------------------------------------------------------------------------------------------------- 79
Hussain Ahmad Khaqan et al ----------------------------------------------------------------------------------------------------------------------- 82
Mohammad Kashif et al ----------------------------------------------------------------------------------------------------------------------------- 85
Prof. Laal Mohammad et al ------------------------------------------------------------------------------------------------------------------------- 90
Ophthalmology Update Vol. 13. No. 2, April-June 2015
ƒƒ
Causes of Low vision and Quality of Life after Rehabilitation in Children & Adults
ƒƒ
Intraocular Pressure Control after The Efficacy of Limbal Based Conjunctival Flap
in Patients Undergoing Trabeculectomy with Intra-operative Mitomycin C
Mohammad Kashif et al ------------------------------------------------------------------------------------------------------------------------------ 93
Hasan Yaqoob et al ---------------------------------------------------------------------------------------------------------------------------------- 100
ƒƒ
Normal Tension Glaucoma & Cerebral Ischemia / Brain Atrophy
ƒƒ
Complications & Results of External Dacryocystorhinostomy in Chronic
Dacryocystitis without Intubation (Review of 107 Cases.)
Akhunzada Muhammad Aftab et al ------------------------------------------------------------------------------------------------------------- 104
Mohammad Alam et al ----------------------------------------------------------------------------------------------------------------------------- 107
ƒƒ
Recurrence of Retinal Detachment after Silicone Oil Removal
ƒƒ
Choroidal Melanoma in a Young Patient
Bilal Khan et al -------------------------------------------------------------------------------------------------------------------------------------- 110
Hussain Ahmad Khaqan et al ---------------------------------------------------------------------------------------------------------------------- 113
„„ GENERAL SECTION / ORIGINAL ARTICLES
ƒƒ
ƒƒ
Frequency of High Glasgow Blatchford Score & its One Month Mortality in
Patients presenting with Non-variceal Upper Gastrointestinal Bleeding
Imran Yahaya et al ---------------------------------------------------------------------------------------------------------------------------------- 115
Meatal Mobilization Technique for Childhood Hypospadias Repair,
an Early Experience at Lady Reading Hospital, Peshawar
Muhammad Ayub Khan et al ---------------------------------------------------------------------------------------------------------------------- 120
„„ OPHTHALMOLOGY NOTEBOOK
ƒƒ Obituary- Forever Loved - Forever Missed ---------------------------------------------------------------------------------------- 123
ƒƒ Murree: The Queen of Mountains - A Shining Pearl of Pakistan (Malika-e-Kohsaar) ------------------------ 124
Ophthalmology Update Vol. 13. No. 2, April-June 2015
iii
Meibomian Gland Dysfunction (MGD)
(Current Concept)
Meibomian Gland Dysfunction, also referred to
as the posterior blepharitis, is a very common cause of
a myriad of symptoms in the general population, particularly after the age of 45 years which is often neglected and under-diagnosed by the ophthalmic fraternity.1
Many ocular disorders, including evaporative dry eye,
blepharitis, sties, chalazia and ocular rosacea have been
linked to abnormal function of the meibomian glands2.
Health professionals in the USA have now been alerted that MGD is a major contributing factor in ocular
surface disease in at least 50 - 75% cases. According
to the International Workshop on Meibomian Gland
Dysfunction in 2011, sponsored by the Tear Film and
Ocular Surface Society, USA,2 there is a paradigm shift
in the treatment of dry eyes. As a result of this report,
ophthalmologists are now evaluating the lids more
carefully, and more often when seeing patients with
dry-eye complaints. MGD has also been known to be
an important cause contact lens intolerance.3
Pathogenesis: Normally there are 40 meibomian
glands in the upper lid and 20 in the lower. As the
glands make meibum, it is normally pushed outward
with each blink by the contraction of Riolan’s muscle
(pre-tarsal orbicularis) on to the surface of eyelids and
spreads over the lid margin making it a smooth sur-
Ophthalmology Update Vol. 13. No. 2, April-June 2015
face which can glide and spread the tear film from the
tear meniscus in the lower conjunctival fornix, evenly
over the cornea, giving it its polished appearance.4 Bacteria (staphlococci which are the normal flora of the
eyelid) invade the meibomian glands and produce lipases which break down the waxy esters in meibum
to short chain free fatty acids.5 These fatty acids are
toxic to the ocular surface and causes its irritation. The
lack of waxy esters result in excessive evaporation of
aqueous component of the tear film. The abnormally
functioning glands may over secrete toxic meibum,
under secrete or get blocked, with underlying changes
to the eye. Normally the meibum is in a fluid state at
normal body temperature but these short chain fatty
acids clump together making the meibum viscid.6 This
thick, opaque secretion blocks the meibomian gland
orifices, dries up and plugs them (seen in the top pic).
When the gland becomes obstructed by thick, inspissated secretion, the glandular epithelium degenerates
and stops functioning altogether, leading to minimal or
nonexistent production of meibum and loss of meibomian glands. The areas where the meibomian glands
have atrophied appears as notches at the grey line (seen
in the bottom picture). Meibomian gland secretion is
controlled by androgens, mainly testosterone. Its defi-
49
EDITORIAL

ciency is particularly seen as a part of normal ageing
process. Hence, dry eye syndrome and MGD is more
commonly seen in post-menopausal women.7
MGD causes two problems: Firstly, eyelid inflammation and secondly, excessive evaporation of tears and
consequently dry eyes. The tears become hyperosmoler
which then stimulate corneal nerves resulting in ocular
irritation, dryness, tearing, redness, a foreign body sensation or intermittent blurring of vision.
Examination: In every adult patient who has come to
you with any eye complaint, try to assess for MGD and
look for the following first:
i) The lids may look normal but the lid margin has to be
everted a little bit and the meibomian gland orifices examined; normally the meibum is a clear secretion that
flows easily out of the orifices with a tiny pressure at
the lid margin with a cotton-tip applicator. However,
an opaque secretion is abnormal. Or, the glands could
be completely blocked / plugged with thick white secretion which cannot be expressed with pressure on the
lid margin. Scarred and notched grey line indicates loss
of glands. Hence, there are different stages of meibomian gland disease.
ii) Grades of MGD:
Grade 0: Normal, no MGD: clear, thin secretion at the
gland orifices, squirts out of orifices with a little pressure on the lid margin.
Grade 1: a viscid secretion flows out easily with minimum pressure.
Grade 2: an opaque secretion flows after exerting a lot
of pressure.
Grade 3: gland orifices are plugged/capped and no secretion flows or it comes out like a tooth-paste or a froth
is present at the lid margins (due to saponification of
fatty acids by bacterial lipases).
Grade 4: atrophic/scarred gland orifices.
NOTE: Toxic secretions cause an inferior conj / corneal
staining. If the ducts are blocked with thick meibum
plugs, or have atrophied, then there will be no toxic secretions; however, if few ducts are open, then a little
bit of corneal staining will be there. Hence seeing corneal staining with open ducts is Grade 2 disease. Seeing corneal staining + majority of ducts being capped/
blocked is grade 3 disease. If grey line shows notching,
then trans-illumination confirms atrophic glands at the
site of a notch (Grade 4 disease).
iii) Oily debris floating in tear film or foam present at
the lid margins indicate hyper-secretion; the fatty acids
undergo saponification by bacteria and produce toxic
foam. iv) Look for Rosacea / recurrent chlazia which indicate
MGD.
50
v) Note the tear-film break up time: this gets reduced
with worsening of the disease. Normal being >10 mm.
vi) Punctate keratopathy at the inferior limbus and inferior conjunctival staining due to irritation by toxic
meibum at the lid margin.
vii) Transilluminate the tarsal plate by a pen-torch held
on the skin side of a fully everted lid to look for evidence of atrophy, loss or degeneration of the meibomian glands.
viii) Check for aqueous deficiency of tear film with
Schirmer’s 2 test.
ix) Check the tear osmolarity if possible.
x) In severe MGD, check lipid profile/ Blood Sugar.
Don’t assume patients will voluntarily mention their
symptoms. Be proactive, and ask every adult patient
about ocular irritation and whether it is worse in the
morning which points to MGD. A dry eye due to
aqueous deficiency is worse in the evening.
Treatment:
a) Highest on the list is getting the patient to play an
active role by scrubbing the lid margins with a baby
shampoo twice a day to remove excess oil.
b) Mobilize the oils 8 out of the lids onto the eye where
you do want them. Achieve this through the use of lid
compresses, which are believed to melt plugs composed of dried secretions blocking the gland orifice;
Apply hot fomentation to the lids with a hot towel to
melt the thick secretions/plugs and then expressing
meibomian glands on a daily basis by massaging the
lower lid upwards and upper lid downwards with a
finger or a Q-tip. this should be done 2-3 x per day. This
will not work in Grade 4 disease in whom there are no
secretions at all due to atrophic glands.
c) Addressing the source of any inflammation; avoid
aminoglycocides topically as they worsen MGD. Find
out and treat any allergies. Topical tetracycline eye
ointment massaged into the id margins twice per day.
Systemic doxycycline9 can interfere with the lipases
produced by Staphlococci that break down the fatty
components to free fatty acids- a common regimen is
doxycycline 100 mg od or b.i.d. for four to six weeks,
in severe cases. An alternative is Azithromycin 500 mg
bid or 1 Gm od per week for 3 consecutive weeks. Similarly, cyclosporin10 eye drops 0.5% - 0.75% twice a day
have the same anti-inflammatory affect.
d) Neutralize toxic secretions with artificial tears; drops
during day and lubricating ointment at night.
e) Some patients are beyond the point of no return.
They don’t have any glands left, or the ones they have
aren’t functioning. For them, heating and massaging
won’t do anything. They can be given Lipid-based artificial tears.
Ophthalmology Update Vol. 13. No. 2, April-June 2015
EDITORIAL

f) Oral Omega 3 Fatty acids11 to restore the balance between good and bad lipids.
g) Intra-ductal probing12 of blocked meibomian glands
has been found to be effective in removing dried secretion.
Recommendation: MGD is a very common eye problem; try to look for it in every adult who presents at the
ophthalmic clinic. Every patient should be specifically
asked for symptoms of ocular irritation. An eye examination should commence from the lids.
It is important to familiarize with the normal meibomian secretion by examining the lids of teenagers first
and trying to squirt out meibum with a gentle squeeze
on the lid margin.
REFERENCES
1. Bron AJ, Tiffany JM. The contribution of meibomian disease to
dry eye. Ocul Surf. 2004;2(2):149–165.
2. The definition and classification of dry eye disease: report of
the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007) Ocul Surf. 2007;5(2):75–92. 3. Korb DR, Henriquez AS. Meibomian gland dysfunction and
contact lens intolerance. J Am Optom Assoc. 1980;51(3):243–
251. 4. McCulley JP, Shine WE. The lipid layer of tears: dependent on
meibomian gland function. Exp Eye Res 2004;78:361-5.
5. Dougherty JM, McCulley JP. Bacterial lipases and chronic
blepharitis. Invest Ophthalmol Vis Sci.1986;27(4):486–491.
Foulks GN. The correlation between the tear film lipid layer
and dry eye disease. Surv Ophthalmol.2007;52(4):369–374.
7. Sullivan DA, Sullivan BD, Evans JE. Androgen deficiency, meibomian gland dysfunction, and evaporative dry eye. Ann New
York Academy Sciences 2002;966:211-222
8. Olson MC, Korb DR, Greiner JV. Increase in tear film lipid
layer thickness following treatment with warm compresses
in patients with meibomian gland dysfunction. Eye Contact
Lens. 2003;29(2):96–99.
9. Dougherty JM, McCulley JP, Silvany RE, Meyer DR. The role of
tetracycline in chronic blepharitis. Inhibition of lipase production
in staphylococci. Invest Ophthalmol Vis Sci. 1991;32(11):2970–
2975.
10. Rubin M, Rao SN. Efficacy of topical cyclosporine 0.05%
in the treatment of posterior blepharitis. J Ocul Pharmacol
Ther. 2006;22(1):47–53. 11. Macsai MS. The role of omega-3 dietary supplementation in
blepharitis and meibomian gland dysfunction (an AOS thesis) Trans Am Ophthalmol Soc. 2008;106:336–356.
12. Maskin SL. Intraductal meibomian gland probing relieves
symptoms of obstructive meibomian gland dysfunction. Cornea. 2010;29(10):1145–1152
6. Dr. Sameera Irfan, FRCS
Consultant Oculoplastic Surgeon & Strabismologist
Mughal Eye Trust Hospital, Lahore, Pakistan
Website: www.sameerairfan.com Cell: 03364500901
ELECTION RESULT
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
President Elect General Secretary Treasurer
Joint Secretary Dr. Waheed Afzal
Prof Farooq Afzal
Dr Shahzad Saeed
Prof Nadeem Qureshi
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
51
OPHTHALMIC SECTION
ORIGINAL ARTICLE
Tayyaba Gul
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
ABSTRACT:
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.
INTRODUCTION
Ocular motor nerves are comprised of Oculomotor (supplying Medial Rectus, Superior Rectus, Inferior
Rectus, Inferior Oblique), Trochlear (innervating Superior Oblique) and Abducent (nerve to the Lateral Rectus). Ocular motor nerve palsies are either supra nuclear or infra nuclear. Associated neurological signs and
symptoms help us determine the site of lesion. Fascicular palsies of third nerve are associated with different
syndromes (Benedikt, Weber, Nothnagel and Claude).
Similarly, fascicular lesions of sixth nerve are associated with Foville and Millard-Gubler syndromes.1 Fourth
nerve palsies are usually congenital in nature.
Different causes of isolated nerve palsies are mentioned in literature. These include vascular diseases
like Diabetes and Hypertension. In Oculomotor palsy
associated with Diabetes and Hypertension, pupils
are usually spared. Aneurysms and trauma are other
important causes of isolated nerve palsies. Tumours,
neurosyphilis and Giant cell arteritis are rare causes.
Associate Professor of Ophthalmology, 2Professor, Department of
Radiology, 3Associate Professor of Ophthalmology, Lahore Medical
and Dental College, Tulspura, North Canal Bank,Canal Road, Lahore
1
Correspondence: Dr. Tayyaba Gul Malik FCPS, Associate Professor
of Ophthalmology, Lahore Medical and Dental College, Lahore
E.mail: tayyabam@yahoo.com, Mob: 0300-4217998
Received: January 2015
52
Accepted: February 2015
Very interestingly, idiopathic palsies constitute a large
percentage in clinical practice. Acoustic neuroma, basal
skull fractures, naso-pharyngeal tumours and raised
intracranial pressures are culprits of sixth nerve pathologies2. Cavernous sinus pathologies give rise to multiple cranial nerve palsies (oculomotor, trochlear, abducent, ophthalmic and maxillary divisions of trigeminal
nerves). This study reviews the neuro-imaging patterns
of ocular motor nerve palsies in a selected group of patients from two tertiary care hospitals of Pakistan.
SUBJECTS AND METHODS
It was a descriptive retrospective study. 50 patients with acquired isolated Ocular motor nerve (Oculomotor, Trochlear and Abducent) palsies were selected (from two centers of Lahore City). Study period
spanned over 2010 to 2014.
Inclusion criteria:
• Patients with acquired isolated third, fourth or
sixth cranial nerve palsies
• Patients whose, complete clinical and radiological
data was available.
Exclusion criteria:
• Patients with multiple cranial nerve palsies
• Patients with incomplete clinical and imaging data
We reviewed clinical and imaging charts of selected patients and medical records were analyzed.
Clinical data included history, visual acuity, color vision 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,
cover/un-cover tests and fundoscopy. Neuro-imaging
tests included Computerized tomography with both
plain and post contrast images, MRI with T2 and T1
weighted plain and post contrast images, (Gd-DTPA
used for post contrast component), magnetic resonance
arteriography and venography. Data was compiled, results deduced and descriptive statistical analysis was
done.
RESULTS
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 presentation. 58% of the patients had right sided nerve palsies
and 42% had left sided involvement. None of our patients had bilateral palsies. Normal imaging scans were
seen in 44% patients. 13 out of 33 (39.39%) patients with
oculomotor nerve palsy had negative scans. The patients with normal MRI and third nerve palsy had normal pupils. 9 out of 17 (52.9%) patients with Abducent
nerve palsy showed no positive findings on neuro-im-
aging. 11 patients with normal scans had uncontrolled
diabetes. Details of neurological scans are shown in
graphs 1,2 and 3. The commonest etiologies of third
nerve palsy (with positive neuro-imaging results) were
brainstem infarcts and maxillary sinusitis while demyelinating disease was major cause of sixth nerve palsy.
Graph-3: Comparison of Oculomotor and Abducent nerve palsies
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
Graph-2: Neuroetiology of sixth nerve palsy
Ophthalmology Update Vol. 13. No. 2, April-June 2015
Figure-2: Right para sellar meningioma (T2 and T1) coronal /axial
post contrast images showing significant mass effect on right
cavernous sinus, pituitary stalk and optic chiasm.
53
Neuro-imaging Patterns of Isolated Ocular Motor Nerve Palsies in a Pakistani Cohort
Parasellar meningioma pressing on the cavernous sinus
was the commonest space occupying lesion leading to
oculomotor ( 6%, n= 2/33) and abducent nerve palsies
(5.88, n= 1/17). Only one case of Acoustic neuroma had
sixth nerve palsy. The patient had developed palsy as
a complication of neurosurgery for Acoustic neuroma.
One of our patients with third nerve palsy had multiple
tuberculomas in parasellar region.
DISCUSSION
Out of twelve pairs of cranial nerves, three pairs
supply extra ocular muscles of eyeball. Diabetes, Hypertension, aneurysms, trauma and brain tumours are
the most commonest causes of these nerve palsies. There
are certain cases where cause cannot be found and they
are considered under the heading of idiopathic. In this
particular study third nerve palsy was the commonest among all ocular motor palsies. It was consistent
with the findings of Kim et al,3 Chih-Hsien Hung4 and
Chiu EK5 Contrary to that, many other researchers had
preponderance of sixth nerve palsy in their studies.4,5,6
Male to female ratio was 1.6:1 in a study by Shawn C in
his cohort with an average age of 66.9 years.4 The ratio
was reverse in our study (1:1.6)
In this particular study, 22% patients (n=11) were
idiopathic. It was very much similar to the figures
given by Kumar9, Rucker et al.10 And Krishna et al.11
While this percentage was quite high by Berlit P12. The
incidence of ocular palsy associated with pituitary tumors is reported to be between 4.6 and 32%.11 We had
parasellar meningiomas leading to ocular motor palsy
but none of our patients had pituitary adenoma. Laterality of palsies is also interesting. 52% of our patients
had right sided palsy which was very much consistent
with an earlier study.12 Headache and diplopia were
the commonest presenting complaints of ocular motor
palsies in our study similar to earlier researchers.13
There are many cases where MRI or other arterial
and venous scans show negative results. Controversy
still exists whether to perform scans in every patient
with isolated ocular motor nerve palsy. One school of
thought in the absence of other neurological signs is to
have a close follow up of the patient. If neurological
findings develop, neuro-imaging should be performed
16,17
. Others have suggested to perform neurological imaging in all patients even if there is evidence of vasculopathy18. In fact, every patient should be thoroughly
investigated and neuro-imaging should be performed
depending upon history, age and examination findings.
This study has certain limitations. Small sample
size could be the cause of absent fourth nerve palsy cas54
es. Our ability to collect detailed information was limited by the retrospective study and we had to rely on
the available data. But this study can provide grounds
on which prospective follow-up studies can be done.
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.
REFERENCES
1.
Kim SH, Lee KC, Kim SH. Cranial nerve palsies accompanying
pituitary tumour. J Clin Neurosci. 2007;14(12):1158-62.
2.
Hung CH, Chang KH, Chu CC,et al. Painful ophthalmoplegia
with normal cranial imaging. BMC Neurol. 2014; 14: 7 3.
Chiu EK, Nicholas JW: Sellar lesions and visual loss: key
concepts in neuro-ophthalmology. Expert Rev Anticancer
Ther 2006; 6(9):23-29
4.
Wilker SC, Rucker JC, Newman NJ, et al. Pain in Ischemic Ocular Motor Cranial Nerve Palsies. Br J Ophthalmol. Dec 2009;
93(12): 1657–1659.
5.
Rowe F and VIS group. Prevalence of ocular motor cranial
nerve palsy and associations following stroke. Eye (Lond). Jul
2011; 25(7): 881–887.
6.
Zafar A, Irfan M. Lateral rectus palsy: An important sign in diagnosing tuberculous meningitis. KUST Med J 2011; 3(1): 10-14.
7.
Kumar MP, Vivekanand U, Umakanth S, Yashodhara BM. A
study of etiology and prognosis of oculomotor nerve paralysis.
Edorium J Neurol 2014;1:1–8.
8.
Rucker CW. The causes of paralysis of the third, fourth and
sixth cranial nerves. Am J Ophthalmol 1966;61(5 Pt 2):1293–8. 9.
Krishna AG, Mehkri MB. India Neurol 1973 Suppl. IV. Vol 20:
584).
10. Berlit PJ. Isolated and combined pareses of cranial nerves III, IV
and VI. A retrospective study of 412 patients..Neurol Sci. 1991
May;103(1):10-5.
11. Greenman Y, Stern N. Non-functioning pituitary adenomas.
Best Practice & Research Clinical Endocrinology & Metabolism 2009, 23:625-638. 12. Nair AG, Ambika S, Noronha VO, Gandhi RA. The diagnostic
yield of neuroimaging in sixth nerve palsy - Sankara Nethralaya Abducens Palsy Study (SNAPS): Report1. Indian J Ophthalmol. Oct 2014; 62(10): 1008–1012.
13. Tamhankar MA, Biousse V, Ying GS. Isolated Third, Fourth
and Sixth Cranial Nerve Palsies From Presumed Microvascular
Versus Other Causes: A Prospective Study. Ophthalmology.
Nov 2013; 120(11): 10.
14. Patel SV, Mutyala S, Leske DA, Hodge DO, Holmes JM. Incidence, associations, and evaluation of sixth nerve palsy using
a population-based method. Ophthalmology. 2004;111:369–75.
15. Murchison AP, Gilbert ME, Savino PJ. Neuroimaging and
acute ocular motor mononeuropathies: a prospective study..
Arch Ophthalmol. 2011;129(3):301-5.
16. Bendszus M, Beck A, Koltzenburg M, et al. MRI in isolated
sixth nerve palsies. Neuroradiology. 2001 Sep;43(9):742-5.
17. Kanski JJ. Neuro-ophthalmology. In: Clinical Ophthalmology:
a systematic approach. 7th Edi. Elsevier Butterworth Heinemann; 2011. p 1055
18. Kanski JJ. Neuro-ophthalmology. In: Clinical Ophthalmology:
a systematic approach. 7th Edi. Elsevier Butterworth Heinemann; 2011. p 1063
19. Kim SH, Lee KC, Kim SH. Cranial nerve palsies accompanying
pituitary tumour. J Clin Neurosci. 2007;14(12):1158-62.
20. Hung CH, Chang KH, Chu CC,et al. Painful ophthalmoplegia
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
22.
23.
24.
25.
26.
27.
28.
concepts in neuro-ophthalmology. Expert Rev Anticancer
Ther 2006; 6(9):23-29
Wilker SC, Rucker JC, Newman NJ, et al. Pain in Ischemic Ocular Motor Cranial Nerve Palsies. Br J Ophthalmol. Dec 2009;
93(12): 1657–1659.
Rowe F and VIS group. Prevalence of ocular motor cranial
nerve palsy and associations following stroke. Eye (Lond). Jul
2011; 25(7): 881–887.
Zafar A, Irfan M. Lateral rectus palsy: An important sign in diagnosing tuberculous meningitis. KUST Med J 2011; 3(1): 10-14.
Kumar MP, Vivekanand U, Umakanth S, Yashodhara BM. A
study of etiology and prognosis of oculomotor nerve paralysis.
Edorium J Neurol 2014;1:1–8.
Rucker CW. The causes of paralysis of the third, fourth and
sixth cranial nerves. Am J Ophthalmol 1966;61(5 Pt 2):1293–8. Krishna AG, Mehkri MB. India Neurol 1973 Suppl. IV. Vol 20:
584).
Berlit PJ. Isolated and combined pareses of cranial nerves III, IV
and VI. A retrospective study of 412 patients..Neurol Sci. 1991
May;103(1):10-5.
29.
30.
31.
32.
33.
34.
Greenman Y, Stern N. Non-functioning pituitary adenomas.
Best Practice & Research Clinical Endocrinology & Metabolism 2009, 23:625-638. Nair AG, Ambika S, Noronha VO, Gandhi RA. The diagnostic
yield of neuroimaging in sixth nerve palsy - Sankara Nethralaya Abducens Palsy Study (SNAPS): Report1. Indian J Ophthalmol. Oct 2014; 62(10): 1008–1012.
Tamhankar MA, Biousse V, Ying GS. Isolated Third, Fourth
and Sixth Cranial Nerve Palsies From Presumed Microvascular
Versus Other Causes: A Prospective Study. Ophthalmology.
Nov 2013; 120(11): 10.
Patel SV, Mutyala S, Leske DA, Hodge DO, Holmes JM. Incidence, associations, and evaluation of sixth nerve palsy using
a population-based method. Ophthalmology. 2004;111:369–75.
Murchison AP, Gilbert ME, Savino PJ. Neuroimaging and
acute ocular motor mononeuropathies: a prospective study.
Arch Ophthalmol. 2011;129(3):301-5.
Bendszus M, Beck A, Koltzenburg M, et al. MRI in isolated
sixth nerve palsies. Neuroradiology. 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 Rao
FCPS, FRCS
Associate Professor of Ophthalmology
QAMC, Bahawalpur, Pakistan
E-mail: drrashadqr@yahoo.com
Ophthalmology Update Vol. 13. No. 2, April-June 2015
55
ORIGINAL ARTICLE
Akhunzada M. Aftab
A Study of Prevalence of Risk Factors in
Patients with Non-Arteritic Anterior Ischemic
Optic Neuropathy (Na- Aion)
Akhunzada Muhammad Aftab FCPS1, Misbah Durrani FCPS2, Asif MBBS3
Awais Rauf MBBS4, Farzana MBBS5, Prof. Mustafaf Iqbal FRCS, FRCOphth6
ABSTRACT
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 abnormalities 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
INRODUCTION
Anterior ischemic optic neuropathy is of two
types; Arteritic and Non Arteritic. Arteritic type is associated with giant cell arteritis. It is associated with
raised inflammatory markers like erythrocyte sedimentation rate (ESR) and C - reactive protein levels. Non
Arteritic Anterior Ischemic Optic Neuropathy is a multi- factorial, acute optic neuropathy. It is the most common optic neuropathy in patients aged over 50 years
and is the second most common cause of optic nerve
related permanent visual loss in adults after glaucoma.1
The pathogenesis of NA- AION involves acute ischemic infarction of the optic nerve head, which is supplied
by the short posterior cilliary arteries (SPAC).2 Despite
the controversies regarding the distributary variations
and characteristics of SPCA anastomoses around the
ON head, it has been proved, that, this circle provides
Registrar Eye A Unit Department of Ophthalmology, Khyber Teaching
Hospital, Peshawar, 2Assistant Professor of Radiology, Bacha Khan
Medical College & Mardan Medical Complex, 3,4,5,Traniee Medical
Officer. A Unit Department of Ophthalmology, Khyber Teaching
Hospital, Peshawar, 6Prof. & Head of Ophthalmology, Khyber
Teaching Hospital, Peshawar.
1
Correspondence: Dr. Akhunzada Muhammad Aftab c/o Prof. Dr.
Muhammad Ibrar, Department of Botany, University of Peshawar,
Peshawar. Cell: 03339106060 E-Mail: draftab@live.com
Received: November 2014
Accepted: December 2014
Financial Disclosure: There has been no financial interest involved
in this study
56
segmental supply to the optic nerve head and physiologically acts as end arteries.3
Patients usually present with sudden painless loss
of vision in one eye, commonly noticed after wakening from sleep. Some patients may present with slight
blurring of vision and a near normal visual acuity is
recorded in them. Several studies have shown high
prevalence of multiple risk factors. These may be considered as local or systemic factors
•Hypertension
• Diabetes Mellitus
•Hyperlipidemia
• Ischemic heart disease
• Nocturnal hypotension
• Sleep Apnea
• Absent or small cup in optic disc, and many
others.4
Some studies have shown intrinsic disorders of
regulation of coagulation as an additional risk factor.2, 5
The purpose of this study was to evaluate the incidence
of these risk factors in patients admitted to Eye A Unit,
Khyber Teaching Hospital, diagnosed with NA-AION.
METHODS
This retrospective chart review study was conducted on patients previously admitted in Eye A Unit
of Khyber Teaching Hospital. Diagnosis of NA- AION
was made considering the following criteria:
• Positive clinical history of sudden painless visual
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.
• Reduced/ near normal visual acuity.
• Presence of relative afferent pupillary defect
(RAPD).
• Diffuse or sectorial optic nerve head edema.
• Central and (or) altitudinal field defect on Humphrey’s visual field.
• Normal ESR and CRP
All the available records including history sheets,
hematological investigations, ophthalmic examination,
fundus photos, visual fields and radiological investigations were reviewed. We evaluated history of onset and
duration of loss of vision. Duration of systemic disease
like diabetes and (or) hypertension was considered.
Also inquiry from the patient and (or) partner regarding noticing symptoms of sleep apnea was also evaluated. 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 activated partial thromboplastin time (APTT), homocysteine 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 included carotid doppler, echocardiography and ECG.
RESULTS
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 (Ranging from 19- 60 years). All (100%) had a positive clinical history of sudden painless loss/ blurring of vision
in the affected eye and presented within 10 weeks of
onset of symptoms (Range 3 days to 10 weeks). Almost
half the study patients (13), reported to have noticed
vision loss upon wakening up in the morning. Only
one (4%) patient’s history was positive for sleep apnea. 14 (58.3%) patients suffered both from diabetes
and hypertension. 2 patients (8.3%) were having only
diabetes and 3 patients (12.5%) were diagnosed hypertensive patients. 5 (20.8%) patients were neither diabetics nor hypertensive. Mean duration of diabetes was
7 years (Range 6 months to 15 years). Mean duration
of hyper tension was 5 years (Ranging from 2 months
to 20 years). All (100%) patients had normal CBC, ESR
and CRP levels. All diabetics had raised HbA1c levels
(mean = 8.7%). 10 out of 17 hypertensive patients in total had raised blood pressure recordings. Patients with
hyper lipidemia were 10 (41.6%).3 patients had raised
cholesterol, 3 had raised triglycerides while 4 patients
had both cholesterol and triglyceride levels above normal.
All 24 (100%) patients had renal function tests, PT
Ophthalmology Update Vol. 13. No. 2, April-June 2015
and APTT levels within normal range.
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 in our study. One
patient was suffering from hepatitis C and was taking
interferon treatment. Fundus photographs revealed 18
(75%) patients in our study to have small discs with
little or no cup. These discs are commonly referred to
as “disc at risk”. Carotid doppler imaging revealed 7
(29%) patients to be having atheromatous plaques in
the carotid arteries. None of these patients had more
than 70% stenosis. Echocardiography revealed abnormalities including diastolic dysfunction (DF) in 15
(62.5%), mitral regurg (MR) in 3 (12.5%), aortic regurg
(AR) in 2 (8.3%), mitral valve prolapse (MVP) in 1 (4%),
while 8 (34%) patients had a normal study.
DISCUSSION
NA- AION is the most common type of ischemic
optic neuropathy. It may or may not be present with
decrease in visual acuity and is usually associated with
visual field defects, respecting the horizontal mid line.
The characteristic clinical features and the associated
risk factors are important in making the diagnosis as
NA-AION is often misdiagnosed as optic neuritis or in
case of diabetics as diabetic papillopathy or even proliferative diabetic retinopathy. It must also be emphasized
that two large studies have looked into the natural history of NA- AION and have reported a spontaneous
improvement in 41%- 43% of eyes.6, 7
The most common presenting feature of NAAION is noticing sudden loss of vision upon awakening. This finding has been reported by 62% patients
in our study. Similar incidence of discovering loss of
vision upon awakening was reported in 73% cases [8].
Regarding visual field defects, a large study has shown
inferior nasal defects to be the most common types of
defects.9 In this study, we concluded that the most common risk factors in our study population for NA-AION
were hypertension (70%) and diabetes (66%) followed
57
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
Singapore,10 the most common risk factor were found
to be hypertension (60%) followed by hyperlipidemia
(51%) and diabetes (49%). In the Ischemic Optic Neuropathy Decompression Trial,11 conducted at 25 US
clinical centers, hypertension (47%) was the most common risk factor, followed by diabetes (24%).
Another study conducted in Malaysia by a. Bawazir et al on 18 patients (20 eyes) at the Hospital University Sains Malaysia from January 2005 until December
2009 revealed hypertension (55%) and diabetes in 44%
patients of NA-AION.12 These studies conducted on
Asian populations are parallel with our findings.
Regarding treatment of NA- AION, multiple therapies have been tried including management of risk
factors, optic nerve sheath decompression, systemic
steroids, Aspirin, Intravitreal triamcinolone and intravitreal bevacizumab.
CONCLUSION
In this study we concluded that the most common
risk factors for NA- AION in our population are hypertension followed by diabetes.
REFERENCES
1.
Arnold AC. Ischemic optic neuropathy. In: Miller NR, Newman NJ, Biousse V, Kerrison JB. Walsh & Hoyt’s Clinical Neuro-Ophthalmology, 6th ed, Vol 1. Baltimore : Lippincott Williams & Wilkins,2005:349-84
2.
Felekis T1, Kolaitis NI, Kitsos G, Vartholomatos G, Bourantas
KL, Asproudis I.Thrombophilic risk factors in the pathogenesis
of non-arteritic anterior ischemic optic neuropathy patients.
Graefes Arch ClinExpOphthalmol. 2010 Jun;248(6):877-84.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Hiraoka M, Inoue K, Ninomiya T, et al. Ischaemia in the
Zinn–Haller circle and glaucomatous optic neuropathy in macaque monkeys. Br J Ophthalmol.2012. doi:10.1136/bjophthalmol-2011-300831
Hayreh SS.Ischemic optic neuropathies - where are we
now?Graefes Arch ClinExpOphthalmol. 2013 Aug;251(8):187384.
Acheson F J, Sanders M D. Coagulation Abnormalities in Ischemic Optic Neuropathies. Eye. 1994;8:89-92
Cullen JF, Chung SHR. Non-arteritic anterior ischaemic optic
neuropathy (NA-AION): Outcome for visual acuity and visual
fielddefects, the Singapore scene 2. Singapore Med J 2012; 53(2)
: 88-90
Ischemic Optic Neuropathy Decompression Trial Research
Group. Characteristics of patients with nonarteritic anterior
ischemic optic neuropathy eligible for the Ischemic Optic
Neuropathy DecompressionTrial. Arch Ophthalmol. 1996;
114:1366-74.
Bawazir A, Gharebaghi R, Hussein A, Wan Hitam WH. Nonarteritic anterior ischaemic optic neuropathy in Malaysia: a 5
years review.Int J Ophthalmol. 2011;4(3):272-274
Hayreh SS, Zimmerman B. Visual field abnormalities in nonarteritic anterior ischemic optic neuropathy: Their pattern
and prevalence at initial examination. Arch Ophthalmol.
2005;123:1554–62
Cullen JF, Chung SHR. Non-arteritic anterior ischaemic optic
neuropathy (NA-AION): Outcome for visual acuity and visual
field defects, the Singapore scene 2. Singapore Med J 2012; 53(2)
: 88-90
Ischemic Optic Neuropathy Decompression Trial Research
Group. Characteristics of patients with nonarteritic anterior
ischemic optic neuropathy eligible for the Ischemic Optic
Neuropathy Decompression Trial. Arch Ophthalmol. 1996;
114:1366-74.
Bawazir A, Gharebaghi R, Hussein A, Wan Hitam WH. Nonarteritic anteriorischaemic optic neuropathy in Malaysia: a 5
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
58
Ophthalmology Update Vol. 13. No. 2, April-June 2015
ORIGINAL ARTICLE
Khalid Shoaib
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 dacryocystorhinostomies 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 turbinate. 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
INTRODUCTION
Dacryocystorhinostomy (DCR) by external(ext)
approach is a gold standard for the management of
obstruction of lacrimal passages beyond the common
canaliculus. However internal approach is also becoming popular now. Through the nose endoscopic (Endo)
DCR can be done either mechanically or with different
types of lasers. Advantages during the procedure include magnified view, bright focal illumination, projection 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 criteria for the study were watering, purulent discharge,
1
3
Eye Specialist, CMH Kharian. 2Eye Specialist, CMH Rawalpindi
Eye Specialists, Lahore. 4RMI, Peshawar.
Correspondence: Col. Khawaja Khalid Shoaib, Eye Department,
CHM Mardan. E-mail: kkshoaib@gmail.com, Ph: 0333-8533550
Ophthalmology Update Vol. 13. No. 2, April-June 2015
chronic dacryocystitis or mucocele and obstruction at
or beyond common canaliculus. Cases having punctual
stenosis or eversion and those having canalicular obstruction, were excluded from the study.
Fig-1: Endonasal DCR with endoscope, camera and
projection on monitor
A 30 degree nasal endoscope was used and packing with ribbon gauze (soaked in 2% xylocaine with
adrenaline 1: 100000) was done for fifteen minutes, in
59
Dacryocystorhinostomy - is Endonasal Endoscopic Approach A Viable Option
all the cases. In the initial ten cases, fiber optic light pipe
(20/23 G) was passed through the canaliculi into the
sac and at the site of transilluminated light, mucosal
incision was made. As the bone was absent in the five
endo cases, a probe was passed from canaliculi to nose
to identify the area. In the initial ten procedures, only
nasal packing mentioned above was done. In the next
ten operations, after packing, injection of the same solution (2 cc of 2% xylocaine with adrenaline1:100000
mixed with 0.5 cc of adrenaline 1: 1000) was given at
the sac area and middle turbinate). Packing was done
again for ten minutes. In the next fifteen procedures,
after packing, cautery was done to achieve haemostasis. Intermittent packing of ribbon gauze soaked in 2 %
xylocaine with adrenaline 100000 was required for brief
periods especially when bone was removed with the
punch and sac wall was incised. In all the cases, silicon
tube (Eagle, USA) was passed and ribbon gauze soaked
in one ml of mitomycin C (0.5 mg/ml) was placed at the
osteotomy site for ten minutes. DCR tube was removed
after six months in all the cases except in two who have
not yet completed six month post operative stenting.
Data was analyzed using SPSS version 15. Descriptive
statistics were used to describe the results.
Fig-2: Endo DCR instruments
RESULTS
Under general anesthesia (GA), a total of 35 endo
DCR were done in 34 patients. 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
6 to 10 months (6.5 + 2.5). During the operation problems encountered were moderate bleeding obscuring
view during six (17%) and difficulty in localization of
sac area in five (14%) procedures (Table 1). Post operative complications included mild bleeding on first post
operative day after three (9%), nasal mucosal adhesions
after one (3%) and persistent watering after six (17%)
procedures requiring re-operation with endonasal endoscopy. Repacking controlled post op bleeding nose.
Persistent watering after five operations (16%) required
re-operation with endonasal endoscopy. Success rate
after the first operation was 83% and after the second
operation was 94%, two cases did not improve, one was
dealt with external DCR and the other was operated
third time by endo DCR.
60
Table-1: Per and post operative problems / complications
Sr. No
1
2
Problems / complications
Bleeding in the nose obscuring view
through endoscope
Difficulty in localization of sac area inside
the nose
Frequency (%)
6 (17)
5 (14)
3
Mild bleeding on first post operative day
3 (9)
4
Nasal mucosal adhesions
1 (3)
5
Persistent watering after operations
6 (17)
DISCUSSION
DCR is more frequently required in females. This
series had around 90% females and included initial
endo DCR cases of the surgeons. It was thought that
males are less concerned of cosmetic appearance of the
scar and moreover it would be difficult to break the
hard bones in them, so a few males were dealt with external approach. All of the cases reported for DCR tube
removal six months after the operation except the two
who had not completed the six month stenting period.
After tube removal, only those patients visited who had
persistent problem.
Fiber optic light pipe was required in each case in
the initial ten cases and was used occasionally in rest
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 endoscope. 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
same solution (2 cc of 2% xylocaine with adrenaline
mixed with 0.5 cc of adrenaline 1: 10000) in the next
ten cases though improved haemostasis but resulted in
increased heart rate/blood pressure as the absorption
from nasal mucosa was very rapid. In the rest of the
cases, cautery was found very useful. Surgery can be
done with the endoscope only while attaching camera
and monitor provide the surgeon and assistant, a magnified view. Ronguers/punch of smaller diameter (Fig
2) are easier to manipulate in the narrow nasal cavity.
Granulation formation occluding rhinostomy site leads
to failure of the procedure and recurrence of epiphora.
To prevent it, different dosages of Mitomycin C have
been used eg. 0.5 mg/ml for 10 minutes,1 0.5 mg/ml for
5 min,2 0.2 mg/mL for 2 min,3 0.05% nasal pack for 48
hours,4 0.03% with silicone intubation5 and 0.2 mg/ml
for 30 minutes.6 In the present study 0.5 mg /ml for 10
min did not cause any problem. Initial half of the cases
in this series were done by combined efforts of eye and
ENT surgeons while later half of the cases were done
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.
Endo DCR has been done for dacryocystocoele in
a 4 month old infant7 and in adults8,9 It has been found
to be safe and effective procedures for the management
of persistent epiphora in children10 and for adults.11 The
common insertion of the upper and lower canaliculus
of the lacrimal sac has been repaired with endoscopic
DCR followed by silicone stenting.12 Formation of mucosal flaps at the end of the operations has been claimed
to improve success rate13, 14 and has been termed powered endonasal DCR by some while many used the
term mechanical endonasal dacryocystorhinostomy
(MENDCR)15 when there is large rhinostomy and mucosal flaps. Success rates of MENDCR 92%14 and 93.5%16
were found to compare favorably with that of standard
external DCR 95.8%.17 In a few studies, success was inferior (86% endo - 94% ext)17 with endo DCR18 while in
other studies, success rates after endo DCR have been
found to be equal to that of external DCR.19 Many think
that best endo DCR results are achieved by stenting or
removal of the medial wall of the lacrimal sac.20 while a
few recommend no intubation because of similar surgical success rates, and granulation formation, patient
discomfort, and increased cost with intubation.21 Nasal
endoscopy has been recommended before and after external DCR2 and to treat a failed external DCR.23
CONCLUSION
Problems/complications encountered during
Endo DCR can be managed as the procedure has good
success rate.
REFERENCES
1.
Angela M. Dolmetsch. Nonlaser Endoscopic Endonasal Dacryocystorhinostomy with Adjunctive Mitomycin C in Nasolacrimal Duct Obstruction in Adults. Ophthalmology Volume 117,
Issue 5, Pages 1037-1040 (May 2010)
2. Dolmetsch AM, Gallon MA, Holds JB. Nonlaser endoscopic
endonasal dacryocystorhinostomy with adjunctive mitomycin C in children. Ophthal Plast Reconstr Surg. 2008 SepOct;24(5):390-3.
3. Tabatabaie SZ, Heirati A, Rajabi MT, Kasaee A. Silicone intubation with intraoperative mitomycin C for nasolacrimal duct obstruction in adults: a prospective, randomized, double-masked
study. Ophthal Plast Reconstr Surg. 2007 Nov-Dec;23(6):455-8
4. Rathore PK, Kumari Sodhi P, Pandey RM. Topical mitomycin
C as a postoperative adjunct to endonasal dacryocystorhinostomy in patients with anatomical endonasal variants. Orbit.
2009;28(5):297-302.
5. Nemet AY, Wilcsek G, Francis IC. Endoscopic dacryocystorhinostomy with adjunctive mitomycin C for canalicular obstruction. Orbit. 2007 Jun;26(2):97-100
6.
Liao S, Kao S, Tseng J, Chen M, Hou P. Results of intraopera-
Ophthalmology Update Vol. 13. No. 2, April-June 2015
tive mitomycin C application in dacryocystorhinostomy. Br J
Ophthalmol. 2000 August; 84(8): 903–906.
7. Mladina R., Stiglmayer N., Dawidowsky K., Jukic T., Jurlina
M., Trupkovic-Fotivec B. Endonasal endoscopic dacryocystorhinostomy for dacryocystocoele in a 4 month old infant. Br J
Ophthalmol. 2001 January; 85(1): 110.
8. Eloy P, Martinez A, Leruth E, Levecq L, Bertrand B. Endonasal
endoscopic dacryocystorhinostomy for a primary dacryocystocele in an adult. B-ENT. 2009;5(3):179-82.
9.
Plaza G, Nogueira A, González R, Ferrando J, Toledano N. Surgical treatment of familial dacryocystocele and lacrimal puncta
agenesis. Ophthal Plast Reconstr Surg. 2009 Jan-Feb;25(1):52-3.
10. Marr J E, Drake-Lee A, Willshaw H E. Management of childhood epiphora. Br J Ophthalmol. 2005 September; 89(9): 1123–
1126.
11. Shiraz Aslam, Abdul Hamid Awan, Mohammad Tayyab. Endoscopic Dacrocystorhinostomy: A Pakistani Experience. Pak J
Ophthalmol 2010; 26 (1):2-6
12. Khan H A, Bayat A, De Carpentier JP. Endoscopic Dacrocystorhinostomy in Lacrimal Canalicular Trauma. Ann R Coll Surg
Engl. 2007 January; 89(1): 43.
13. Trimarchi M, Giordano Resti A, Bellini C, Forti M, Bussi M.
Anastomosis of nasal mucosal and lacrimal sac flaps in endoscopic dacryocystorhinostomy. Eur Arch Otorhinolaryngol.
2009 Nov;266(11):1747-52.
14. Sonkhya N, Mishra P. Endoscopic transnasal dacryocystorhinostomy with nasal mucosal and posterior lacrimal sac flap. J
Laryngol Otol. 2009 Mar;123(3):320-6.
15. Tan NC, Rajapaksa SP, Gaynor J, Nair SB. Mechanical endonasal dacryocystorhinostomy--a reproducible technique. Rhinology. 2009 Sep;47(3):310-5.
16. Tsirbas A, Davis G, Wormald PJ. Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy.
Ophthal Plast Reconstr Surg. 2004 Jan;20(1):50-6.
17. Leong SC, Karkos PD, Burgess P, Halliwell M, Hampal S. A
comparison of outcomes between nonlaser endoscopic endonasal and external dacryocystorhinostomy: single-center experience and a review of British trends. Am J Otolaryngol. 2010
Jan-Feb;31(1):32-7.
18. Zílelíog˘lu G, Tekeli O, Ug˘urbas SH, Akiner M, Aktürk T, Anadolu Y. Results of endoscopic endonasal non-laser Dacryocystorhinostomy. Documenta Ophthalmologica 105: 57–62, 2002
19. Leong SC, Macewen CJ, White PS. A systematic review of outcomes after dacryocystorhinostomy in adults. Am J Rhinol Allergy. 2010 Jan-Feb;24(1):81-90.
20. de Souza C, Nissar J. Experience with endoscopic dacryocystorhinostomy using four methods.Otolaryngol Head Neck
Surg. 2010 Mar;142(3):389-93.
21. Unlu HH, MD, Gunhan K, Baser EF, Songu M. Long-term results in endoscopic dacryocystorhinostomy: Is intubation really required?Otolaryngology–Head and Neck Surgery (2009)
140, 589-595
22. Elmorsy SM, Fayk HM. Nasal endoscopic assessment of
failure after external dacryocystorhinostomy. Orbit. 2010
Aug;29(4):197-201.
23. Choussy O, Retout A, Marie JP, Cozlean A, Dehesdin D. Endoscopic revision of external dacryocystorhinostomy failure.
Rhinology. 2010 Mar 2;48(1):104-107.
61
ORIGINAL ARTICLE
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
ABSTRACT
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 international standards despite use of single vial for multiple doses and multiple settings.
Key words: Bevacizumab, Intravitreal, Neovascularization, Proliferative Diabetic Retinopathy.
INTRODUCTION
Vascular Endothelial Growth Factors (VEGF)
plays an important role in many ocular pathologies,
both of the anterior and the posterior segment, leading mainly to complications like neo-vascularization
and macular edema. Since the introduction of anti- vascular endothelial growth factor therapy in 2005, it has
gained wide spread popularity among ophthalmologists worldwide.1-6 Although not FDA approved, ‘off
label’ use of Bevacizumab has been in practice since
June 2005.7 It has been used with promising results in
conditions like Age related macular degeneration, proliferative diabetic retinopathy, neovascular glaucoma,
clinically significant diabetic macular edema and macular edema due to vascular occlusions.1,3-6,8-10
Commercially available bevacizumab (Avastin®;
Registrar Eye A Unit Department of Ophthalmology, Khyber Teaching
Hospital, Peshawar, 2,3,4Traniee Medical Officers, A Unit Department
of Ophthalmology, Khyber Teaching Hospital, Peshawar, 5Prof. &
Head of Ophthalmology Department, Khyber Teaching Hospital,
Peshawar, 6Registrar, Ophthalmology Department, Khyber Teaching
Hospital, Peshawar.
1
Correspondence: Dr. Akhunzada Muhammad Aftab c/o Prof. Dr.
Muhammad Ibrar, Department of Botany, University of Peshawar,
Peshawar. Cell: 03339106060, E-Mail: draftab@live.com
Received: January 2015
Accepted: February 2015
Financial disclosure: There has been no financial interest involved in
this study
62
Genetech, San Francisco USA is available in preservative-free 100 mg/4 ml vials, and is intended for use at
relatively high concentrations on a single colon cancer
patient. In this era of tremendous emphasis on health
care cost containment in both developed and developing countries, it is a common practice among hospitals,
clinics, and compounding pharmacies to divide the
large volume of bevacizumab into smaller units that are
suitable for single-use intravitreal doses for individual
eyes.11
MATERIALS AND METHODS
Avastin® service is being provided in Department
of Ophthalmology, Khyber Teaching Hospital, Peshawar since August 2011. The duration of this report is
from 1st January 2012 to 31st December 2012. A retrospective analysis of all the Avastin patients admitted
in the department during the period was done as part
of the annual audit of the service. After elaborating
detailed history of decreased vision, all the patients
underwent complete ophthalmological examination
including visual acuity using the Snellen’s visual acuity charts, best corrected visual acuity, intraocular pressure (IOP) measurement using the Goldman applanation Tonometer, pupils, slit- lamp examination for
anterior and posterior segment evaluation and dilated
fundus examination using the 90D lens (Volk, USA).
All intravitreal Avastin were advised by consultant
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
exclude any cardiovascular risk factors and blood pressure monitoring. Written informed consent was taken
from all the patients.
Intravitreal 2.5mg/ 0.1ml Bevacizumab (Avastin®)
was injected in sterile environment of operation theater
under strict aseptic technique using topical anesthesia.
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
sterile box in a refrigerator (80 C). Standard procedure
for injecting Intravitreal Avastin was followed. Topical proparacaine 0.5% drops were used for anesthesia
followed by instillation of 5% povidone Iodine in the
conjuctival sac. Periocular scrubbing and sterile draping 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 indirect Ophthalmoscopy. All the patients received topical
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 pressure measurement, anterior chamber evaluation especially for signs of inflammation and (or) endophthalmitis, 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 injection to be given.
RESULTS
Total number of patients receiving Avastin during the specified time period was 867. Demographic
analysis revealed 59% males (n= 512) and 41% (n= 355)
females. The most common age group in our study
was 56-65 years (38%) followed by 46-55 years group
(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 diabetic retinopathy (PDR) with macular edema (42%), followed by clinically significant macular edema (CSMO)
with non proliferative diabetic retinopathy (NPDR)
(29%). Indication of macular edema secondary to venous occlusion was present in 10% patients. Complete
breakdown of the different indications for intravitreal
Avastin of this study period is given in figure II and
Table I.
Regarding the ocular complications, the most
common was sub conjunctival hemorrhage (2.19%), folOphthalmology Update Vol. 13. No. 2, April-June 2015
lowed by crystalline lens trauma with needle (0.69%),
which led to traumatic cataract. Post operative endophthalmitis was present in only one (0.11%) patient. Other
complications observed included transient rise in IOP,
regurgitation of drug and mild uveitis. None of our patients experienced any systemic side effects during the
study duration. Figure III explains breakdown of the
complications.
TABLES & FIGURES
Figure-I: Distribution of different Age groups in our study
Figure II: Indications for Intravitreal Avastin therapy. PDR (Proliferative Diabetic Retinopathy), CSMO (Clinically Significant
Macular Oedema), NPDR(Non Proliferative Diabetic Retinopathy),
CRVO(Central Retinal Vein Occlusion), BRVO(Branch Retinal vein
Occlusion), NVG(Neovascular Glaucoma), CSR(Central Serous
Retinopathy), AMD(Age Related Macular Degeneration
Indication
No of
Patients
Indication
No of
Patients
PDR with Macular Edema
367
NPDR with CSMO
253
CRVO, BRVO
87
Iris
Neovascularization
17
NVG
42
Wet AMD
37
Vitreous Hemorrhage
38
CSR
08
Myopia
06
Eales Disease
12
Table I: Indication (s) of Intravitreal Avastin Therapy. PDR
(Proliferative Diabetic Retinopathy), CSMO(Clinically Significant
Macular edema), NPDR(Non Proliferative Diabetic Retinopathy),
CRVO(Central Retinal Vein Occlusion), BRVO(Branch Retinal vein
Occlusion), NVG (Neovascular Glaucoma), CSR(Central Serous
Retinopathy), AMD(Age Related Macular Degeneration)
63
Ocular and systemic Complications of Intravitreal Bevacizumab (Avastin) therapy
Figure-3: Ocular & Systemic complications during the study
period. PEE (Punctate Epithelial Erosions of cornea)
DISCUSSION
Anti VEGF injections have become a revolutionary
treatment modality in the last decade. Its use in ophthalmologic pathologies has yielded promising results.
“of label” use of Bevacizumab (Avastin)is gaining wide
popularity not only because of the promising results
but also its easy availability and a relatively cheap cost.
As already mentioned most centers, hospitals and clinics divide the vial into multiple small doses, reducing
the cost per injection further.
The dose of Bevacizumab used in ophthalmology
is small as compared to the intravenous dose used in
carcinoma colon, still, various ocular and systemic complications have been reported worldwide.7, 10- 15 In our
study, out of a total of 867 patients, only 36 patients developed ocular side effects of the therapy while no patient experienced any systemic side effects in the study
duration. Out of these 36 patients, 29 had per operative
complications like sub conjunctival hemorrhage, crystalline lens trauma and regurgitation of drug. The most
common age group in our study was 56- 65 years (38%),
and the most common indication for therapy was proliferative diabetic retinopathy with macular edema
(42%). Ocular complications in our study included subconjuctival hemorrhage (2.1%), crystalline lens trauma
(0.6%) which led to traumatic cataract, transient rise of
intra ocular pressure (0.3%), mild uveitis (0.2%), endophthalmitis (0.1%), conjunctival injection with punctate epithelial erosions (0.1%) and regurgitation of drug
(0.4%). No patient (0%) had any systemic side effects in
the study duration.
In another study conducted by Fasih U et al, out of
150 patients receiving intravitreal bevacizumab, ocular
complications included sub conjunctival hemorrhage
(23%), regurgitation of drug (5.3%), transient rise of
IOP (4.7%), mild uveitis (2.7%), lens injury (2%), con64
junctival chemosis and iatrogenic vitreous hemorrhage
(0.7%). Among the reported systemic complications
were acute rise of blood pressure (2.7%) and mild irritation 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 patients 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 intravitreal bevacizumab therapy in 707 patients. Results of
their study included corneal abrasion 2 patients (0.28%),
Conjunctival chemosis 2 patients (0.28%), Crystalline
lens injury1 patient (0.14%), ocular inflammation 2 patients (0.28%), retinal pigment epithelial (RPE) tear1
patient (0.14%) and acute vision loss1 patient(0.14%).
Systemic complications included cerebral infarction 1
patient(0.14%), elevation of systolic blood pressure 2
patients (0.28%), facial skin redness 1 patient (0.14%),
itchy diffuse rash 1 patient(0.14%)and menstrual irregularities 3 patients (0.42%).17 While in our study complications like RPE tear, sudden loss of vision and systemic side effects were not seen. A retrospective study
conducted by Johnson D et al, at the Department of
Ophthalmology, Queens Hospital Kingston, Ontario,9
(1.30%) cases of acute intraocular inflammation were
seen out of 693 injections given.18
CONCLUSION
Intravitreal Bevacizumab therapy has fewer side
effects as compared to systemic administration. The
ocular side effects of our study are well within range of
international studies. In order to avoid systemic complications, admission of all the patients and strict cardiovascular evaluation is mandatory. Using the same
vial for multiple doses and being used in multiple settings do not seem to increase the risk of ocular and (or)
systemic complications. Multiple dosing from a single
vial can reduce the total patient cost tremendously. The
operative complications can be avoided by adopting
proper procedure and employing trained ophthalmologists for the procedure.
REFERENCES
1.
Avery RL, Pieramici DJ, Rabena MD, et al. Intravitreal bevacizumab (Avastin)for neovascular age-related macular degeneration. Ophthalmology2006;113:363–72.
2.
Manzano RP, Peyman GA, Khan P, Kivilcim M. Testing intravitreal toxicity ofbevacizumab (Avastin). Retina 2006;26(3):257–61.
3.
Spaide RF, Fisher YL. Intravitreal bevacizumab (Avastin) treatment of proliferative diabetic retinopathy complicated by vitreous hemorrhage. Retina2006;26:275–8.
4.
Iturralde D, Spaide RF, Meyerle CB, Klancnik JM, Yannuzzi
LA, Fisher YL, Sorenson J, Slakter JS, Freund KB, Cooney M,
Fine HF. Intravitreal bevacizumab (Avastin) treatment of macular edema in central retinal vein occlusion: a short-term study.
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5.
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Retina 2006;26:279–84.
Avery RL. Regression of retinal and iris neovascularization
after Intravitreal bevacizumab (Avastin) treatment. Retina
2006;26:352–4.
Mason JO III, Albert MA Jr, Vail R. Intravitreal bevacizumab
(Avastin) for
Refractoryp seudophakic cystoid macular edema. Retina
2006;26:356–7.
FungA E, RosenfeldP J, ReichelE. The International Intravitreal
Bevacizumab SafetySurvey: using the internet to assess drug
safety worldwide. Br J Ophthalmol 2006;90:1344-49.
Kahook MY, Schuman JS, Noecker RJ. Intravitreal bevacizumab in a patient withneovascular glaucoma. Ophthalmic Surg
Lasers Imaging 2006;37:144-6.
Spaide RF, Laud K, Fine HF,Klancnik JM Jr, Meyerle CB, Yannuzzi LA, Sorenson J, Slakter J, Fisher YL, Cooney MJ. Intravitreal bevacizumab treatment ofchoroidal neovascularization secondary to age-related macular Degeneration. Retina
2006;26(4):383–90.
Rich RM, Rosenfeld PJ, Puliafito CA,Dubovy SR, Davis JL,
Flynn HW Jr, Gonzalez S, Feuer WJ, Lin RC, Lalwani GA,
Nguyen JK, Kumar G. Short-term safety and efficacy of intravitreal bevacizumab (avastin) for neovascular age-related
macular degeneration. Retina 2006;26(5):495–511.
Danny S N, Alvin KK, Clement WC, Walton WT. Intravitreal
bevacizumab: safety of multiple doses from a single vial for
consecutive patients. Hong Kong Med J 2012;18:488-95.
Ladas ID, Karagiannis DA, Rouvas AA, Kotsolis AI, Liotsou
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19.
A, Vergados I. Safety of repeat intravitreal injections of bevacizumab versus ranibizumab: our experience after 2,000 injections. Retina. 2009; 29(3):313-18.
Fintak DR, Shah GK, Blinder KJ, et al. Incidence of endophthalmitis related to intravitreal injection of bevacizumab and
ranibizumab. Retina. 2008; 28(10):1395– 99.
Diago T, McCannel CA, Bakri SJ, Pulido JS, Edwards AO, Pach
JM. Infectious endophthalmitis after intravitreal injection of antiangiogenic agents. Retina. 2009; 29(5):601– 05.
Wu L, Martinez- Castellanos MA, Quiroz-Mercado H, Arevalo JF, Berrocal MH, Farah ME, Maia M, Roca JA, Rodriguez
FJ; Pan American Collaborative Retina Group (PACORES).
Twelve-month safety of intravitreal injections of bevacizumab
(Avastin): results of the Pan-American Collaborative Retina
Study Group (PACORES). Graefes Arch Clin Exp Ophthalmol.
2008; 246(1):81–87.
Fasih U, Shaikh N, Rahman A, Sultan S, Fahimi MS, Shaikh A.
Ocular and systemic complications of intravitreal injection
bevacizumab( avastin ) in one year follow up(a study of 150
cases). J Pak Med Assoc. 2013;63(6):707-10.
Shima C, Sakaguchi H, Gomi F, Kamei M, Ikuno Y, Osh,
Sawa M, Tsujikawa M, Kusaka S, Tano Y. Complications in
patients after intravitreal injection ofbevacizumab. Acta Ophthalmol. 2008; 86:372–76.
Johnson D, Hollands H, Hollands S, Sharma S. Incidence and
characteristics of acute intraocular inflammation after intravitreal injection of bevacizumab: A retrospective cohort study.
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
histopathology.
Curtesy: Dr Hussain Ahmad Khaqan Department of Ophthalmology, Lahore
General Hospital/PGMI, Lahore.
Ophthalmology Update Vol. 13. No. 2, April-June 2015
65
ORIGINAL ARTICLE
M. Idris
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
ABSTRACT
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, Peshawar 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 students, 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.
INTRODUCTION
Penetrating ocular trauma is a serious type of injury to the globe. Intraocular foreign bodies (IOFBs)
are the major cause of penetrating ocular trauma and
the most serious problem is the resulting impairment
of visual function. Special attention should be paid on
primary and secondary complications, which include
mechanical lesions of the ocular tissues, metallosis
and endophthalmitis.1 Ocular trauma associated with
intraocular foreign bodies (IOFBs) is one of the major causes of visual impairment in young individuals.
Various reports indicate that 18-41% of all open globe
injuries involve at least one IOFB.2
In a study, the intraocular foreign body in open
globe injury was found in 45 eyes (38%). In our study
it was seen in 37% cases.3 Most of the victims are male
Medical Officer, Ophthalmology UNIT, PGMI, LRH Peshawar, KPK,
Senior Medical Officer, Ophthalmology UNIT, PGMI, LRH Peshawar,
KPK, 3Consultant, Ophthalmology UNIT, North West General, Hospital, Peshawar, KPK, 4Medical Officer, Ophthalmology UNIT, PGMI,
LRH Peshawar, KPK.
1
2
Correspondence: Dr. Mohammad Idris, Medical Officer, Ophthalmology UNIT, PGMI, Lady Reading Hospital, Peshawar.
Cell No.: +92-333-9182595, Email: idrisdaud80@gmail.com
Postal Address: Ophthalmology UNIT, PGMI, LRH Peshawar, KPK
Received: August 2014
66
Accepted: November 2014
and young patients working on fields which are exposed because of their occupations. In this regard, lack
of awareness regarding protective goggles and early
referral to eye specialist for urgent management is lacking.4, 5 Most ocular injuries in this rural population occurred at the workplace, suggesting the need to explore
workplace strategies to minimize ocular trauma as a
priority. Eye care programs targeting high-risk ocular
trauma groups may need to consider ocular trauma as
a priority in eye health awareness strategies in order to
reduce its incidence.6
METHODOLOGY
The study was carried out at Department of Ophthalmology, Govt Lady Reading Hospital, Peshawar
from July 2010 to Jan 2013. We received 100 cases from
outdoor department and were admitted for management. This was a prospective, interventional case series
of consecutive patients with IOFBs. Patients were examined after detailed history and important finding were
noted. The following variables were recorded for the
purpose of the study: age, gender, cause of trauma, occupation, complications, presenting best-corrected visual acuity (BCVA), slit lamp and fundus examination,
ultrasound examination when ophthalmoscopy was
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, consequences of retained IOFB including complications, time
interval since injury, details were recorded. All patients
underwent surgical removal of the IOFB. Final visual
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 disease especially diabetic retinopathy, high myopia, past
ocular surgery and bleeding disorders.
RESULTS
We analyzed 100 cases of patients who suffered
penetrating ocular trauma. Various aspects of subjects
with penetrating trauma are presented in Table1. Regarding gender distribution, 73 (73%) patients were
male and only 27(27%) Patients were female. We divided age into 03 groups. 38 (38%) patients were young
with age less than 20 years. 53 (53%) patients have age
ranging from 21 to 40 years and only 09 (09%) patients
have age 40 years or old. So majority were young patients. Different causes of the penetrating trauma were
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
were found in 12(12%) patients. Finally visual outcome
was shown in table 1., generally the final visual acuity
was poor in majority of the patients. We divided the
patient’s visual acuity into Perception of light (PL) to
no perception of light and counting finger or better.
37 patients were having visual acuity of perception of
light to no perception of light. 63 patients have counting finger or better vision. PL was mostly in BBI and
cases which were presented late. So majority had poor
prognosis even after treatment, at six months follow
up period. Main reason for poor visual acuity was late
presentation and BBI.
Table 2 shows frequency of IOFB in 100 cases presented to the emergency department for management.
out of 100 cases, 37 (37%) patients have IOFB detected either clinically or using imaging techniques like,
X-rays, CT-scan and ultrasound B-scan. In 63 (63%)
patients with penetrating ocular injury, no IOFB was
Ophthalmology Update Vol. 13. No. 2, April-June 2015
found.
Table1: Clinical characteristics of subjects
with penetrating trauma (N=100)
number percentage
Age
5-20 years
21-40 years
41 above
38
53
9
38
53
9
Gender
Male
Female
73
27
73
27
Causes of intraocular injury
Hammering a chisel
Bomb blast injury
Sports or accidental
others
33
17
44
6
33
17
44
6
occupation of patients
Labor
Sports and defense
Students
Others / accidental
35
15
38
12
35
15
38
12
Final visual outcome
Perception of light to no perception of light No
Counting finger or better
37
63
37
63
Table-2: Frequency of intraocular foreign
body in penetrating trauma
Frequency
N
%
Yes
37
37
No
63
63
Total
100
100
Fig-1: Different Intra Ocular Foreign Bodies recovered
from the globe: (photo by DR MOHAMMAD IDRIS, eye unit,
Lady Reading Hospital, Peshawar)
DISCUSSION
In this study we evaluated cases with penetrating intraocular injury that underwent repair and with
or without foreign body removal. The visual outcomes
and complications of surgical management were determined. The final visual acuity, and important observations reported in the literature were compared to the
present study.
With successive wars in the twentieth century, there has been a relative increase in injuries to
the eye compared to injuries of other parts of the body.
The main causes of eye injury have changed with advances in techniques and weaponry of warfare, with
blast fragmentation injuries accounting for 50-80% of
cases.7 In our study, Mostly victims are those working
in the field and exposed to environment. According
67
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
having worse prognosis and despite proper management and early intervention, results and final visual
outcome were poor and disappointing. It was mainly
because of multiple and complex type of injuries and
severe ocular damage.
The most common causes of open globe injury
are domestic accidents and occupational injuries. Significant prognostic factors for final visual outcome in
patients with open globe injury are initial visual acuity,
posterior extent and length of wound, presence of hyphaema and presence of vitreous prolapse. Awareness
of the factors predicting a poor visual outcome may be
helpful during counseling of patients with open globe
injuries.10
Several studies confirm that trauma of any type
is common in male11 in our study males were in majority also. Similarly young to middle age people are
the common group of people exposed to both accidental as well as occupational trauma.4, 5 Most of our patients were less than 40 years age. Penetrating ocular
injuries with retained posterior segment foreign bodies are challenging cases requiring urgent attention by
vitreoretinal surgeons. Posteriorly located injuries can
result in serious immediate and delayed vitreoretinal
sequelae, such as retinal detachment and endophthalmitis. De Souza S et al, reported the rates of retinal detachment and endophthalmitis were 41% (17/41) and
17% (7/41) respectively.12 Several studies have shown
that the visual prognosis is poor. In a study, Visual acuity on admission between 6/60 to PL comprises highest
number (64%) and also on discharge between 6/60 to
PL comprises highest number of cases (50%) of IOFB.3
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 inflammation to warrant their removal. Removal of organic foreign bodies, however, is mandatory since these objects
usually lead to secondary infection, like endophthalmitis.13
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.
68
Visual progression was poor in majority of the eyes due
to delayed presentation and BBI were the top reasons.
Most serious cause of penetrating trauma was BBI. FBs
like wood and stone were strongly associated with endophthalmitis which needs local and systemic antibiotics should be advocated in any trauma particularly
contaminated ones.
Recommendations: Awareness regarding early referred to the tertiary care hospital, when facilities of vitrectomy is available for IOFB removal with out delay.
Any FB can enter the eye and cause damage so the need
of imaging is stressed in every suspected case.Majority
of patients with IOFB were male, laborer and workers,
so the incidence can easily be reduced with adopting
simple measures like safety goggles use during work
because in most of the cases prognosis is poor and prevention is better.
REFERENCES
1
Obuchowska I, Napora KJ, Sidorowicz A, Mariak Z. [Clinical
characteristics of penetrating ocular injuries with intraocular
foreign body. Part I. Pathogenesis and clinical features]. Klin
Oczna. 2010; 112:70-6.
2
Kuhn F, Mester V, Morris R. Intraocular foreign bodies. In:
Kuhn F, Pieramici D, editors. Ocular Trauma: Principles and
Practice. USA: Thieme Medical Publishers; 2002.
3
Hossain MM, Mohiuddin AA, Akhanda AH, Hossain MI, Islam MF, Akonjee AR, Ali M.Pattern of ocular trauma. Mymensingh Med J. 2011 ;20:377-80.
4
Han SB, Yu HG. Visual outcome after open globe injury and its
predictive factors in Korea. J Trauma. 2010 ;69:E66-72.
5
Yalcin Tök O, Tok L, Eraslan E, Ozkaya D, Ornek F, Bardak Y.
Prognostic factors influencing final visual acuity in open globe
injuries. J Trauma. 2011 ;71:1794-800.
6
Krishnaiah S, Nirmalan PK, Shamanna BR, Srinivas M, Rao
GN, Thomas R. Ocular trauma in a rural population of southern India: the Andhra Pradesh Eye Disease Study. Ophthalmology. 2006 ;113:1159-64.
7
Wong TY, Seet MB, Ang CL. Eye injuries in twentieth century
warfare: a historical perspective. Surv Ophthalmol. 1997;41:43359.
8
Barak A, Verssano D, Halpern P, Lowenstein A. Ophthalmologists, suicide bombings and getting it right in the emergency
department. Graefes Arch Clin Exp Ophthalmol. 2008 ;246:199203.
9
Wightman JM Gladish SL. Explosions and blast injuries. Ann
Emerg Med. 2001; 37:664-78.
10 Madhusudhan AL, Evelyn-Tai LM, Zamri N, Adil H, Wan-Hazabbah WH. Open globe injury in Hospital Universiti Sains Malaysia - A 10-year review. Int J Ophthalmol. 2014 18;7:486-490.
11 Kinderan YV, Shrestha E, Maharjan IM, Karmacharya S. Pattern of ocular trauma in the western region of Nepal. Nepal J
Ophthalmol. 2012 ;4:5-9.
12 De Souza S, Howcroft MJ. Management of posterior segment intraocular foreign bodies: 14 years’ experience. Can J
Ophthalmol. 1999 ;34:23-9.
13 Karcioglu ZA, Nasr AM. Diagnosis and management of orbital
inflammation and infections secondary to foreign bodies: a
clinical review. Orbit. 1998 ; 17:247-69.
Ophthalmology Update Vol. 13. No. 2, April-June 2015
ORIGINAL ARTICLE
Mehdi Soltanifar
To Determine the Efficacy of Tattoo
Ink in Changing the Color of Rabbit’s Iris
Mehdi Soltanifar MBBS1, Jahanzeb Durrani, DOMS, FICO2
ABSTRACT
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.
INTRODUCTION
The color of the iris has important implications in
the cosmetic appearance of a person’s eyes. Different
optical aids have been developed to change the color of
the iris and hence the appearance of the eyes. These devices include colored contact lenses and anterior chamber intra ocular lenses. Both these aids have their advantages and associated complications. Tattoo ink can
also be used to change the color of the iris. It has been
used in humans on the skin for a long time. The tattoo ink is ingested by the fibroblasts and permanently
changes their color. The aim of this research is to use
tattoo ink to change the color of the iris in animal models. The research will be carried out in rabbit eyes because of their close anatomical resemblance to human
eyes. The eyes will then be monitored for a change in
the color of the iris as well as any possible side effects.
OPERATIONAL DEFINITION
The safety and efficacy of the ink will be judged
according to the following parameters;
1-Intraoccular pressure (IOP) A difference of more
1,2
Postgraduate Trainees for M.S, Ophthalmology PIMS, Islamabad
Correspondence: Dr. Mehdi Soltanifar MBBS, Postgraduate Trainee
for M.S. Ophthalmology, PIMS, Islamabad.
Email: mehdisoltanifar@yahoo.com, Ph: 00989155410462
Received: October 2014
Accepted: November 2014
Ophthalmology Update Vol. 13. No. 2, April-June 2015
than 4 mmHg before and after the procedure will be
considered significant.
2-Anterior chamber reaction: A cell count of more than
fifteen and a flare of more than +2 will be considered
significant.
3-Iris atrophy: The pupillary size and excursion to light
will be compared with the other eye to determine damage to the iris muscles. Iris atrophy will be recorded as
being either present or absent.
4-iris colour: The color of the iris before the use of tattoo ink will be compared to its color after its use.
MATERIAL AND METHODS
Setting: Department of Ophthalmology Pakistan Institute of Medical Sciences, Islamabad.
Duration of Study: 6 months after approval of synopsis.
Sample: Size twenty eyes of ten rabbits with one eye of
each animal being used as control.
Sampling Technique: Non probability (convenience)
sampling.
Inclusion Criteria:
1. Healthy adult rabbits with normal eyes.
2. Age from 2 to 6 months
Exclusion criteria:
1. Any ocular pathology
2. Age less than 2 months and greater than 6 months
Data Collection Procedure: The dye that will be used
to change the color of the iris is standard tattoo ink. The
69
To Determine the Efficacy of Tattoo Ink in Changing the Color of Rabbit’s Iri
concentration of the dye will be standardized by centrifuging one milliliter of ink to remove the fluid followed by washing with normal saline. One milliliter
of hydroxy methyl cellulose will then be added to this
mixture.
All the eyes will undergo intra-ocular pressure
measurement by Schiotz tonometer. The anterior
chamber reaction and iris atrophy will be assessed by
slit lamp biomicroscopy. A record of iris color will be
kept by serial photographs. All these variables will be
measured one day before the injection of tattoo ink then
two weeks after the injection finally one month after the
procedure.
The rabbits will be anesthetized by an intramuscular injection of forty percent ketamine, xylazine Hydrochloride and Atropine. After anesthesia the head
of the rabbit will be fixed. A port will be made at the
limbus at the 12 O’ clock position. Viscoelastic will be
injected in the anterior chamber for deepening it and
protecting the cornea. Finally, preformed tattoo ink will
be injected in the anterior chamber through the same
port. The Anterior chamber will be 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 will be sealed via stromal hydration.
Topical antibiotic-steroid drops will be used to post operatively.
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.
RESULTS
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
70
mean of 27.6±2.37. At 1 week the IOP ranged from 18.5
to 25.8 with a mean of 22.4±3.63. At 1 month the IOP
decreased further and ranged from 14 to 25.8 with a
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 significantly 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 however 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
month the condition was the same as at 1 week. The
flare in AC was significantly more at 1 week and at 1
month as compared to the baseline; p=0.009.
Pupillary reaction: Two rabbits however developed
sluggish left pupil at 1 week and at 1 month.
Iris atrophy: Iris atrophy was not seen in any rabbit at
the baseline and also not at 1 week or 1 month.
Color change of iris: 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.
Histopathology: 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.
Ophthalmology Update Vol. 13. No. 2, April-June 2015
To Determine the Efficacy of Tattoo Ink in Changing the Color of Rabbit’s Iri
Differences between different colors: The response observed with different colors was varied. For example
with blue and yellow color the change in color was homogenous however with brown, green and red color
the color change was patchy and inhomogeneous.
DISCUSSION
Different optical aids have been developed to
change the color of the iris and hence the appearance of
the eyes. These devices include colored contact lenses
and anterior chamber intra ocular lenses. Both these
aids have their advantages and associated complications. Anterior chamber intra ocular lenses have been
used to mask the original color of the iris and improve
the appearance of patients with iris colobomas. The
complications associated with these include uveitis, iris
atrophy, glaucoma, endophthalmitis, pupillary abnormalities, haloes and reduced vision at night. Colored
contact lenses are easy to use and are widely employed
to change the color of the iris for cosmetic reasons. Contact lens use has been associated with uveitis, epithelial
keratopathy and allergic reactions. Tattoo ink can also
be used to change the color of the iris. The immediate
uptake of the ink by the fibroblasts, together with the
scarcity of these cells in the endothelial layer of the cornea and anterior capsule of the lens ensures that these
structures in the anterior chamber do not change their
color and react minimally to the presence of the ink.
We carried out a study at PIMS hospital to see the
efficacy of tattoo ink in changing color of iris. The study
was carried out at Department of Ophthalmology,
PIMS Islamabad. The research was carried out on rabbit eyes. The response observed with different colors
was varied. For example with blue and yellow color the
change in color was homogenous however with brown
and red color the color change was patchy and inhomogeneous. Each tattoo color has a different chemical
formula which is a secret of the company manufacturing it. The differences observed in the homogeneity of
color change may be due to differences in the chemical
nature of the different colors.
From our study it is evident that the color change
occurs if the dye is retained in the anterior chamber for
24 hours. Complications included features of inflammation which settled by the end of one month in some
eyes. It caused complications of decreased intraocular
pressure and increased anterior chamber cell count and
flare. No iris atrophy occurred. The reduction in the
Ophthalmology Update Vol. 13. No. 2, April-June 2015
intraocular pressure in rabbits´ eyes may be due to reduced fluid production by the ciliary body in response
to the dye. However, reduced pressure does signify the
fact that the tattoo ink did not block the outflow tracts
of the anterior chamber.
Tattoo inks have their own hazards even when
used on the skin, In our study the injection of tattoo
ink was associated with development of inflammation
as evidenced by significant increase in cell count and
development of flare in the anterior chamber. However, tattoo ink was quite safe in our study since no
case of iris atrophy was observed. Since the previous
methods had their own limitations attempts at inventing a new method that is successful in changing the eye
color without side effect will continue. Our study was
one such effort. Further studies are required in the field
with slight changes in the tattoo chemistry and its solvent that can improve the results in future.
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 and yellow ink are homogenous and whole iris color change occurred.
REFERENCES
1.
Druianova IUS, Verigo EN, A rational method of cosmetic eye
prosthesis. Vestn Oftalmol1990;106:53-4. 2005;18:454-64.
2. Mamalis N: Complications of foldable intraocular lenses
requiring explantation or secondary intervention. J Cataract
Refract Surg 2002;28: 2193-201.
3. Sorbara L., Jones, L. Williams-lyn D. Contact lens induced
papillary conjunctivitis with silicone hydrogel lenses. Cont
Lens Anterior Eye 2009;32:93-6
4. Möhrenschlager M, Worret WI, Köhn FM. Tattoos and
permanent make-up: background and complications. MMW
Fortschr Med 2006;148:34-6.
5.
Bron AJ, Tripathi RC, Tripathi BJ. Wolff’s Anatomy of the Eye
and Orbit.8th edn. Chapman & Hall Medical: London, 1997.
6.
Imesch PD, Wallow IH, Albert DM. The colour of the human eye:
a review of morphologic correlates and of some conditions that
affect iridial pigmentation. SurvOphthalmol1997;41:117–23. 7.
Wilkerson CL, Syed NA, Fisher MR, Robinson NL, Wallow
IH, Albert DM. Melanocytes and iris colour. Light microscopic
findings. Arch Ophthalmol 1996;114:437–42.
8.
Prota G, Hu DN, Vincensi MR, McCormick SA, Napolitano
A. Characterization of melanins in human irides and cultured
uveal melanocytes from eyes of different colours. Exp Eye Res
1998;67:293–99. 9.
Fuchs E. Normal pigmentierte und albinotische iris. Graefes
Arch ClinExpOphthalmol1913;84/85:521.
10. Dieterich CE. [The fine structure of melanocytes in the human
iris].Graefes Arch ClinExpOphthalmol1972;183:317–33.
71
ORIGINAL ARTICLE
Bilal Bashir
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
ABSTRACT:
Purpose: To determine the frequency of sero-positive cases of Hepatitis B & C viral infection in the admitted patients undergoing 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 doctors, paramedics and other patients.
BACKGROUND
Hepatitis is described as an infection with swelling and inflammation of the liver that if progresses,
may lead to cirrhosis or cancer. Sometimes people contract hepatitis with limited or no symptoms but often
it leads to jaundice, anorexia (poor appetite) and diarrhea. Hepatitis is caused by a wide variety of causatives
like alcohol, poison and autoimmunity but most cases
of hepatitis are reported by viruses. Pakistan has large
number of both diagnosed and un-diagnosed patients
of hepatitis B and C. The prevalence among general
public of HBV and HCV infection in Pakistan is 10%2,3
and 4–10%4,5 respectively. Hepatitis B virus (HBV) infection is endemic worldwide and is responsible for
an estimated 1-2 million deaths worldwide every year.
About 350 million (5- 15 % of the total cases) are carriers
of the virus, out of which around 80% reside in Asia.6
According to WHO estimates, HCV prevalence is 3% of
world population with 170 million cases. Almost 50%
of all cases become chronic carriers at risk of liver cirrhosis and liver cancer.7
HBV can be transmitted through blood, semen,
vaginal fluids and other bodily fluids of the infected
individual.8 HCV however, can only be contracted
through blood to blood contact. The transmission risk
1,4
Medical Officers Lady Reading Hospital Peshawar. 2Assistant
Professor Naseer Teaching Hospital Peshawar. 3Medical Officer Al
Khidmat Hospital Peshawar. 5Assistant Professor Lady Reading
Hospital Peshawar
Correspondence: Dr. Bilal Bashir, House no 103 New Defence
Officers Colony Shami Road Peshawar Cantt Ph: 03339115764 /
091-5270869 Email: drbilal85@hotmail.com
Received: November 2014
72
Accepted. January 2015
of these diseases is more among patients receiving
blood transfusions or injection drug users.9,10 Patients
presenting to different public and private hospitals are
not routinely screened for hepatitis B and C. Therefore there is high risk of transmission of infection from
asymptomatic carrier patients. Keeping in view the
dreadful complications of hepatitis and its high infectivity we cannot take the risk of operating on patients
without hepatitis screening. This study was carried out
to discover the frequency of hepatitis B and C in our
surgical patients to get an idea about the number of the
patients we are operating on them without knowing
that whether they are hepatitis B or C positive.
MATERIAL AND METHODS
This prospective observational study was conducted at Eye Unit, Lady Reading Hospital Peshawar
from July 2013 to June 2014. A total of 1147 patients under going eye surgery, who were unaware of hepatitis
infection were included in this study. After taking ethical approval from the department, patients informed
consent was taken. Rapid chromatography immunoassay for qualitative detection of hepatitis B and C was
the screening method. Those found positive on screening test are confirmed by ELISA. A special proforma
is made for this study and results were analyzed by
statistical methods.
RESULTS
Total number of patients screened were 1147. Male
subjects were 54.31% (623/1147) and female subjects
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. 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
females. The frequency of HCV was 66.66% (24/36) in
males and 33.33% (12/36) in females. No patient was
diagnosed with both Hepatitis B and C co infection.17
DISCUSSION
The incidence of hepatitis B and C has achieved
endemic situation in many countries of the world, especially in under developed countries. Pakistan also has
high prevalence of Hepatitis B and C. Most common
source of spread of these infections is through the use
of unsterilized syringes or instruments especially dental instruments or unchecked blood transfusion. Other
factors involved in the spread of infection are persons
who have their face shaved by street barber or those
involved in sexual abuse.11,12,13
In our study the frequency of Hepatitis B and C is
2.5% and 3.13% respectively. In other study by Sheikh
and his colleagues15 carrier state of HBs Ag was found
to be 2.8 %. According to Chaudhary and his colleagues
the prevalence of hepatitis C was 11.26%.14 In another
study done by Weis and his co workers at John Hopkins, 4% patients admitted for surgery had HBV and
35% had HCV.16
In our study the prevalence of Hepatitis B and C
was more in males (54.31%) than in females (45.68%). In
another study done by Naeem and co workers, Hepatitis B and Hepatitis C prevalence in preoperative cataract patients was found to be higher in males(59.18%)
than females (40.82%).17 Iftikhar et al also showed that
Ophthalmology Update Vol. 13. No. 2, April-June 2015
the total prevalence of Hepatitis B & C in males was
higher than females among preoperative cataract patients of D I Khan.18 Surprisingly some studies have
shown higher prevalence of Hepatitis B and C in females than in males.19 A study conducted in different
Eye camps of Pakistan in 2010 showed higher prevalence of the diseases in females with 60.18% than in
males with 39.81%.20
CONCLUSION
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 mandatory in all preoperative patients. This will prevent transmission 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.
REFERENCES
1.Hepatitis http://www.nlm.nih.gov/medlineplus/hepatitis.
html
2. Yusaf A, Mahmood A, Ishaq M, et al. Can weafford to operate on patient without HBsAg screening. J Coll Phys Surg Pak.
1996; 9:98-100.
3.
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..
4. Malik IA, Khan SA, Tariq WUZ. Hepatitis C virus in prospective: where do we stand, (editorial ). J Coll Phys Surg Pak. 1996;
6: 185-6
5. Umar M, Bushra HT, Shuaib A, et al. Spectrum of chronic liver
disease due to HCV infection. J Coll Phys Surg Pak. 1999; 9:
234-7.
6. World Health Organization: Hepatitis B. (Fact sheet no. 204).
Geneva,Switzerland: World Health Organization; 2000.
7. World Health Organization: Hepatitis C. (Fact sheet no. 204).
Geneva, Switzerland: World Health Organization; 2000.
8. Maheshwari A, Thuluvath PJ: Management of acute hepatitis
C. Clinics in liver disease 2010, 14(1):169–176
9. The ABC’s of Hepatitis: http://www.hepfi.org/living/liv_
abc.htm
10. Department of Ophthalmology Liaquat University of Medical and Health Sciences Jamshoro from July 2007 to June 2008.
Managing Occupational Risks for Hepatitis C Transmission in
the Health care setting. Clin Microbiol Rev. 2003; 16: 546-68
11. Luby S. The relationship between therapeutic injections and
high prevalence of hepatitis C infection in Hafizabad. Pakistan.
Epidemiol Infection. 1997; 119: 349-56
12. Khuwaja AK, Qureshi R, Fatimi Z. Knowledge and attitude
about hepatitis B and C among patients attending family medicine clinics in Karachi. Eastern Mediterranean Health J. 2002; 8:
1-6.
13. Thornburn D, Roy K, Camerson SO. Risk of hepatitis C virus
transmission from patient to surgeons. Gut 2003; 52; 1333-8.
14. Chaudhary IA, Khan SA, Samiullah. Should we do the hepatitis B and C screening on each patient before surgery. Pak J Med
Sci. 2005; 21; 278-80.
15. Shaikh MH, Shams K. Prevalence of HBV in health care personnel and methods of control. J College of Physicians and Surgeons Pak. 1995; 5: 19-21.
16. Makary ESW, Weis MA. Prevalence of blood borne pathogens
in an urban university based general surgical practice. Ann
73
Incidence of Hepatitis B & C among Admitted Eye Patients in Tertiary Care Hospital of Peshawar
Surg. 2005; 24: 803-9
17. Syed Saad Naeem, Efaza Umar Siddiqui, Abdul Nafey Kazi,
Sumaiyatauseeq Khan, Farhan E Abdullah, Idrees Adhi. Prevalence of hepatitis ‘B’ and hepatitis ‘C’ among preoperative cataract patients in Karachi.. BMC research notes 2012; 5(492).
18. Ahmad I, Khan SB, Rehman HU, Khan MH, Anwar S: Frequency of Hepatitis B and Hepatitis C among cataract patients.
Gomal Journal of Medical Sciences 2006, 4:2.
19. Farooqi JI, Farooqi RJ: Relative Frequency of Hepatitis B and
Hepatitis Cvirus infections in patients of cirrhosis in NWFP,
Pakistan. J Coll Phys Surg Pak 2000, 10:217–219.
20. Nangrejo KM, Qureshi MA, Sahto AA, Siddiqui SJ: Prevalence
of Hepatitis B and C in the patients Undergoing Cataract Surgery at Eye Camps. Pak J Ophthalmol 2011, 27:1
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74
Ophthalmology Update Vol. 13. No. 2, April-June 2015
ORIGINAL ARTICLE
Visual Outcome & Complications of
Scleral-fixation Posterior Chamber Intraocular Lenses
Mir Ali Shah
Mir Ali Shah FCPS. Fellow Vitreo-Retina1, Bilal Khan2, Bilal Khan3
Bilal Bashir4, Sher Akbar Khan5, Mohd Jawad6, Muhammad Idris7
ABSTRACT:
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 Hospital, 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 placement 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.
INTRODUCTION
While crystalline lens subluxation can occur in any
patient, these three profiles are most prone: significant
blunt trauma to the eye or head; systemic conditions
such as Marfan’s syndrome, homocystinuria, familial
ectopia lentis, Weill-Marchesani syndrome, aniridia
and Ehlers-Danlos syndrome, hypermature cataract in
which zonular support has been lost. Symptoms of lens
subluxation includes visual disturbance from extreme
hyperopic or myopic shift, astigmatism or acquired
aphakia. Acute secondary angle closure glaucoma can
occur due to subluxated lens.1 Children with monocular
aphakia who become contact lens intolerant require an
intraocular lens (IOL) for visual rehabilitation. When
there is inadequate support from the posterior lens capsule, use of an anterior chamber IOL(AC IOL) or PCSFIOL may be considered. The authors reported their experience with scleral fixation of posterior chamber IOLs
in children. Implantation of a PCSF IOL for the surgical
management of aphakia in the absence of capsular supAssociate Professor, Department of Ophthalmology, PGMI Lady
Reading Hospital Peshawar. 2,4,5Resident,Vitreo-Retina. 3Resident
Neuro Surgery. 6Postgraduate Trainee Department of Ophthalmology,
Lady Reading Hospital, Peshawar. 7Medical Officer Ophthalmology,
Lady Reading Hospital Peshawar.
1
Correspondence: Dr. Mir Ali Shah, Associate Professor, Department
Ophthalmology, Lady Reading Hospital, Peshawar.
Email: drmashahpsh@gmail.com Cell: 03005948091
Received: December 2014
Accepted: January 2015
Ophthalmology Update Vol. 13. No. 2, April-June 2015
port is a safe procedure with a low risk of complications in the early postoperative period.2 Suture related
complications are unique to PCSF IOL. To avoid erosion of the knots through conjunctiva, scleral flaps can
be used to cover the knots.3 The partial thickness scleral flaps can atrophy over time and expose the proline
knot. Endophthalmitis has been reported and remains
a real risk in patients undergoing SFIOL.4 The possible
causes of dislocation of these IOLs include suture degradation,5 suture breakage,3 slippage of the haptic from
the suture,3 or erosion of the suture through the tissue.6
Recent studies have shown that the implantation of
scleral fixation posterior chamber intraocular lenses is
feasible and renders more favorable results in children
over 2 years of age if non-compliant with spectacles or
contact lenses.7,8 Implantation of IOLs in children less
than 2 years is still controversially discussed.9,10 Therefore, we have performed a study to compare the outcomes of secondary intraocular lens implantation in
aphakic eyes of children older than 2 years previously
operated for traumatic and congenital cataracts.
Anterior-chamber lenses were used for many years
because of relatively easy implantation technique, even
in the total absence of capsular support. However, the
fixation in the anterior-chamber angle may cause glaucoma and chronic irritation to the iris. Furthermore,
long-term endothelial cell loss with corneal decompensation is reported for angle-fixated intraocular lenses,
75
Visual Outcome & Complications of Scleral-fixation Posterior Chamber Intraocular Lense
as well as for iris claw lenses fixed to the anterior surface, a technique introduced by Jan Worst almost 30
years ago.
MATERIAL AND METHODS
It is a retrospective study carried out in the Department of Ophthalmology, Lady Reading Hospital,
Peshawar from July 2011 to July 2013. A total of 17 patients of PCSF-IOL were included in the study. Details
of the patient like age, gender, pre- and postoperative
best-corrected visual acuity (BCVA), indication for surgery 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 postoperative complications. Patients were followed for one
year regarding vision and any complications like raised
intraocular pressure (IOP), IOL decentration and suture 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 preoperative 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 polypropylene suture with one end straight and the other curved
needle was used. One straight needle was passed perpendicularly 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 corresponding 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
below the scleral flap to avoid its exposure and to secure the IOL. The scleral wound was closed with interrupted vicryl 7/0 suture or 10/0 nylon. The suture was
covered by the conjunctiva. The IOLs implanted were
single-piece polymethyl-methacrylate (PMMA) lenses
with eyelets(Neo eye). The optic diameter was 6.5 mm
and the overall diameter was 13 mm.
RESULTS
A total of 17 eyes of 17 patients included 14(82.32%)
males and 3(17.68%) females with a male to female ratio
4.6:1 (Figure 1).
The age ranged from 4 to 15 years and were followed over a period of one year after placement of SF76
PC-IOL. All eyes had a PMMA IOL implanted. About
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. 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
(Figure 2). The one eye with dislocation of IOL required
repeat surgery.
Fig-1
Fig-2
DISCUSSION
The lens is supported in a normal eye by zonules,
while support for an IOL is provided by posterior capsule and zonules. When there is no capsuler support
or lack of zonular support, then IOL can be placed between the iris and cornea in anterior chamber with open
or closed loop.11 It can be placed in the ciliarry sulcus as
iris fixated or it can be fixated to sclera in the posterior
chamber.11,12,13 The gender distribution in our series was
a male to female ratio of 4.6:1. There has been an increase in the gender of the male patients resulting from
an increased trauma in Pakistan, increase incidence in
the male gender has been reported in by Ferriera JL22
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 Lense
was 8 yrs and they enjoyed good vision for at least one
year follow up. The mean age reported was from 8.6
years to 10.5 years reported by Bhutto IA15 and Ganesh
A et al16.About 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. The reported range in the improvement in the VA
has been 53.6% by Kumar et al20,17
Complications in our study included temporarily
elevated IOP unrelated to the IOL insertion, which is in
1(5.88%) and PCIOL subluxation requiring revision surgery in 1/17 eyes (5.88%). This low rate may, of course,
increased in the following years, a fact, which has been
published recently.14 Complications encountered in our
study are comparable with those seen in other pediatric scleral-fixated PC IOL studies, and retinal problems
arising from the procedure or endophthalmitis due to a
fistula have not been encountered.19,20
Erosion, breaking or wearing away of the 10×0
polypropylene thread is of some concern, since it has
been shown that fibrous reactions around the IOL haptics is lacking.21,22 In our study there is breakage of suture and dislocation of only one(5.88%) IOL and we did
his second surgery for SF IOL.In an observational case
series by Vote et al., 17 eyes (27.9%) had spontaneous
suture breakage with several eyes having multiple episodes.23 the discrepancy between his and our study is
due to the increase in sample size and long term follow
up by him(4 months vs 3 years). Drews, in his report
noted that polypropylene may fail after a prolonged
period in the eye. The deterioration was most marked
with sutures buried in actively metabolizing ocular tissue.22 there has been a wide range of the incidence in
the literature by various authors from 9.09% to 14.28%
as shown in table 1. Other complications in our study
were IOL dislocations, iris capture, increased IOP and
IOL dislocation; table 1 shows a comparison of complications in our study and that reported by other authors.
Table-1: A comparison of various
complications seen in our study and that reported
by various other authors around the globe
Complications
In our study (%)
Increase IOP
5.88%
Iris capture
5.88%
Glaucoma / suture
exposure
11.66%
IOL dislocation
5.88%
In literature (%)
11% by Buckley EG 14 et al
9.09% By Kumar et al20
3.5% by Narang P et al21
16.66% by Zou Y et al 19
7.1% by Ganesh A et al16
18.18% by Kumar M et al20
14.28% by Sharpe MR et al7
14.28% by Sharpe MR et al7
10.70% by Ganesh A et al16
9.09% by Kumar M et al20
We are convinced that the best place for fixation
of intraocular lenses in the absence of sufficient zonuOphthalmology Update Vol. 13. No. 2, April-June 2015
lar/capsular support is the sclera. It is the strongest intraocular tissue, mainly avascular, and does not have a
tendency toward inflammation.13
For iris claw lenses, uveitis–glaucoma–hemorrhage syndrome has been reported and late dislocations
may occur. Should vitreoretinal surgeons choose to use
this type of lens, I would recommend the retropupillary reverse implantation technique.21 This technique
is much more convenient because it prevents contact
with the corneal endothelium intraoperatively, ie, during fluid-air exchange and postoperatively due to eye
rubbing, blinking etc.13
CONCLUSION
Posterior chamber sclera fixation IOL implantation is a safe technique with minimal complications
when there is no capsular for visual rehabilitation especially in children.
REFERENCES
1. LuoL, LIM,Zong Y, Cheng B, Liu X. Evaluation of secondary glaucoma associated with subluxated lens misdiagnosed as acute primary angle closure glaucoma.J Glaucoma.2013;22:307-10.
2. Luk As,Young Al,Cheng Ll. Long-term outcome of scleralfixated intraocular lens implantation.Br J Ophthalmolol.2013
Oct97(10):1308-11
3. Lewis JS. Abexternosulcus fixation. Ophthalmic Surg. 1991;
22:692–95.
4. . Heilskov T, Joondeph BC, Olsen KR, Blankenship GW. Late endophthalmitis after transscleral fixation of a posterior chamber
intraocular lens. Arch Ophthalmol.1989;107:1427.
5. Price MO, Price FW, Jr, Werner L, Berlie C, Mamalis N. Late
dislocation of scleral-sutured posterior chamber intraocular
lenses. J Cataract Refract Surg. 2005;31:1320–6.
6. Kim J, Kinyoun JL, Saperstein DA, Porter SL. Subluxation of
transscleral sutured posterior chamber intraocular lens (TSIOL) Am J Ophthalmol. 2003;136:382–4.
7. Sharpe MR, Biglan AW, Gerontis CC. Scleral fixation of posterior chamber intraocular lenses in children. Ophthalmic Surg
Lasers. 1996;27:337–341.
8. Ahmadieh H, Javadi MA. Intraocular lens implantation in children. CurrOpinOphthalmol. 2001;12(1):30–34.
9. Lambert SR, Lynn M, Drews-Botsch C, et al. A comparison of
grating visual acuity, strabismus, and reoperation outcomes
among children with aphakia and pseudophakia after unilateral cataract surgery during the first six months of life. JAAPOS. 2001;5:70–75.
10. Lithander J. Prevalence of amblyopia with anisometropia or strabismus among schoolchildren in the Sultanate of
Oman. ActaOphthalmol Scand. 1998;76(6):658–662.
11. Lithander J, Sjóstrand J. Anisometropic and strabismicamblyopia in the age group 2 years and above: a prospective study of
the results of treatment. Br J Ophthalmol.1991;75(2):111–116. 12. Lindquist TD, Agapitos PJ, Lindstrom RL, et al. Transscleral
fixation of posterior chamber intraocular lenses in the absence
of capsular support. Ophthalmic Surg.1989;20:769–775.
13. Scharioth BG. IOL fixation techniques. Retinal Physician. 2009;8:26–8.
14. Buckley EG.Scleral fixated (sutured) posterior chamber intraocular lens implantation in children.J AAPOS. 1999;3(5):289-94.
15. Bhutto IA, Kazi GQ, Mahar PS, QidwaiUA.Visual outcome and
complications in Ab-externoscleral fixation IOL in aphakia in
pediatric age group. Pak J Med Sci. 2013; 29(4): 947–50.
16. Ganesh A, Al-Zuhaibi S, Mitra S, Sabt BI, Ganguly SS, Bialasiewicz AA. Visual Rehabilitation by Scleral Fixation of Posterior
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Chamber Intraocular Lenses in Amblyopic Aphakic Children.
Middle East Afr J Ophthalmol. 2008; 15(2): 61–5.
17. Rehman A,Bhutto IA,Bkhari S,Hassan M,Bhatti MN.Pak J Ophthalmol 2011;27(2):73-7.
18. Lithander J. Prevalence of amblyopia with anisometropia or strabismus among schoolchildren in the Sultanate of
Oman. ActaOphthalmol Scand. 1998;76(6):658–62.
19. Drews RC. Quality control, and changing indications for lens
implantation. The Seventh Binkhorst Medal Lecture-1982. Ophthalmology. 1983;90:301–10.
20. Kumar M, Arora R, Sanga L, Sota LD. Scleral-fixated intraocular lens implantation in unilateral aphakic children. Ophthal-
mology. 1999;106(11):2184-9.
21. Narang P, Narang S. Glue-assisted intrascleral fixation of posterior chamber intraocular lens. Indian J Ophthalmol 2013;
61(4): 163–7.
22. FerreiraJL, F. VeginiF, MaliskaCR. Clove hitch knot for scleral
fixation of dislocated IOL – with temporary externalization of
the haptics through a clear cornea incision. Invest Ophthalmol
Vis Sci 2004;45: E-Abstract 330.
23. Benayoun Y, Petitpas S, Turki K, Adenis J, Robert P. Sutureless scleral intraocular lens fixation: Report of nine cases and
literature review; ; (Jul 2013).J Françaisd’Ophtalmologie 2013;
online.
First Announcement
KAROPHTH 2015
6th, 7th, 8th March 2015
Pearl Continental Hotel, Karachi
Last Date for Abstract Submission
31st Jan 2015
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.
E mail: ospkarachi@yahoo.com
78
Ophthalmology Update Vol. 13. No. 2, April-June 2015
ORIGINAL ARTICLE
Prevalence and Density of Amblyopia in
Strabismic Patients of School Age Children
(A study of 106 cases)
Mohammad Alam
Mohammad Alam FCPS1, Misbah Durrani FCPS2
Prof. Lal Mohammad FCPS3, Irfan Ullah Khan FCPS4
ABSTRACT
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
INTRODUCTION
Strabismus and amblyopia are two most common
pediatric ocular disorders with cosmetic and functional
sequale. Amblyopia is associated with suboptimal vision despite best correction with refraction. In the absence of any other ocular or neural morbidity strabismus is the misalignment of the two eyes which in case
of failure of treatment may result in loss of binocularity
and depth perception1 Failure to diagnose and manage
amblyopia in early age may result in lifelong visual impairment.2 Strabismic amblyopia is a serious blinding
condition affecting the patients in early life. Population-based prevalence estimates in children range from
0.3% to 4.4% strabismic amblyopia.3 Hispanic / Latino
children age of 5 -14 years assessing study in Colombia
Assistant Professor Ophthalmology KMU Institute of Medical Sciences, K.D.A, Kohat. 2Assistant Professor, Radiology, Bacha Khan
Medical College, Mardan. 3Professor of Ophthalmology, KMU Institute Of Medical Sciences, K.D.A, Kohat. 4Refractionist, K.D.A Teaching Hospital, Kohat.
1
Correspondence: Dr. Mohammad Alam1 Assistant Professor Ophthalmology KMU Institute of Medical Sciences K.D.A Kohat. malamktk@
gmail.com, Cell:
Received: December 2014
Accepted: February 2015
Ophthalmology Update Vol. 13. No. 2, April-June 2015
has shown a strabismus prevalence of 3% and amblyopia of 1.3%.4
In developed countries policies are being formulated for early detection of strabismus and amblyopia.5
In Japan children are assessed for strabismic amblyopia
in early age primarily by pediatrician and after 6 years
by ophthalmologist.6 Early detection and treatment of
strabismus and amblyopia are very important. But in
developing countries like Pakistan, children with strabismus present later. According to a local study most
of children with squinting eyes presented after 5 years
of age.7 In comparison to this in developed countries
presentation is early. Some studies have revealed presentation of squinting patients at the age of 2 -5 years.8,9
No reliable data is available in our country and
again there is many differences in data in various studies due to demographic, geographical, social, education and cultural influences over the community. This
study was done to find out the prevalence and density
of amblyopia in strabismic patients of school age children. Then it will be possible for the early detection and
management as well as making the people aware of this
grave problem.
79
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 strabismic school age children with age range of 5 – 15 years with mean age of
7.8 years. A proper proforma was designed. Consent
was taken from the parents/guardians of the children.
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
cover un cover test.
Visual acuity was checked with snellen’s Chart.
Cycloplegic refraction was done with retinoscope. Amblyopia density was graded as mild difference of two
lines, moderate difference of 3 lines and severe with
difference more than 3 lines. Inclusive criteria was children of age 5 -15 years suffering from strabismus while
children with other ocular diseases except squint were
excluded from the study. Total 106 children with age
range of 5 -15 years with mean age of 7.8 years were included. Out of 106 patients 68 (64.15%) were male and
38 (35.84%) were female (Table I). On basis of squint the
children were divided into two groups. Group I had
esotropic and Group II had extropic patients.
RESULTS
Out of 106 patients, 81 (76.41%) children had esotropia (Group 1) while 25(23.58%) had exotropia(Group
II). In esotrpic group 63 (77.77%) had uniocular while
18 (22.22%) had alternating esotropia. Group II had 25
exotropic patients out of which 19 (76%) had uniocular
while 6 (24%) had alternating exotropia. Table II In total
106 patients, 86 (81.13%) had amblyopia with subdivision in different groups and sub groups, the density of
amblyopia is as follow. In uniocular esotropic 63 patients, 60 (95.23%) patients had amblyopia in which 34
(56.66%) had mild, 21 (35%) moderate and 5 (8.33%)
had severe amblyopia. In alternating esotropia, out
of 18 patients 7 (38.88%) patients had amblyopia. Out
which 6 (85.71%) had mild amblyopia while 1 (14.28%)
had moderate amblyopia.
In uniocular exotropic group, out of 19 patients 14
(73.68%) patients had amblyopia in which mild ambly-
opia was present in 9 (64.28%) patients, moderate in 3
(21.42%) patients and 2 (14.28%) had severe amblyopia.
In alternative exotropia out of 6 patients 5 (83.33%) had
amblyopia. In amblyopic patiens 4 (80%) patients had
mild while 1(20.0%) had moderate amblyopia. Table II
Table-I: Gender distribution no. 106
Gender
No of Patients
%age
Male
68
64.15
Female
38
35.84
Table-II: Showing types of strabismus
TYPES OF STRABISMUS
Group I Esotropia No. 81
Group II Exotropia No. 25
SUB TYBE
Uni Ocular
Alternating
Uni Ocular
Alternating
NO OF
PATIENTS
63
18
19
06
%AGE
77.77
22.22
76.00
24.00
DISCUSSION
Strabismus and amblyopia are the most common
ocular conditions during school age children. Strabismus is significant cause of amblyopia and psychosocial
distress.Various studies have proved strabismus to be
the most common cause of amblyopia.10,11 Other causes
of amblyopia are anisometropia, sensory deprivation
and combined pattern.12 Our study was conducted on
106 strabismic school age children for the prevalence
and density of amblyopia. 81(76.41) patients were esotropic while 25 (23.58%) were exotropic. Male were
more than female. Amblyopia was 95.23% in uniocular
esotropic patients with density of mild, moderate and
severe in descending pattern and in 38.88% patients
with alternating esotropia.
In exotropic group of uni ocular 19 patients, 14
(73.68%) patients had amblyopia with mild, moderate
and severe density going down. In alternating exotropic group out of 06 patients 5(83.33%) patients had amblyopia with mild form four- fold more than moderate
density.The results of different studies are different due
to multiple factors like education, demographic pattern, geographic, culture dependence and awareness.
Variation of results are also present in national and international studies.
Mian M Shafique, Naeem Ullah, H Nadeem have
reported amblyopia in 82% of esotropia. They have
Table-III: Showing prevalence and density of amblyopia
Group
Esotropia No. 81
Exotropia No 25
80
Type of
No of Patients
No of Amblyopic (%)
Mild (%)
Moderate (%)
Severe (%)
Uni Ocular
63
60(95.23%)
34(56.66%)
21(35.00%)
5(8.33%)
Alternating
18
7(38.88% )
6(85.71%)
1(14.28%)
0
Uni ocular
19
14(73.68%)
9(64.28%)
3(21.42%)
2(14.28%)
Alternating
06
5(83.33%)
4(80%)
1(20.00%)
0
Total
106
86
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
and was common in esotropia than exotropia.13 Presian
MW, Novak A, have reported in Baltimore Study amblyopia more common in exotropia than esotropia.14,15
Kvarnstrom G, Jakobsson, D have reported in their
study that 44% of amblyopic patients were due to strabismus.16 Ebans Mvogo C, Ellog A etc conducted study
on prevalence of amblyopia in strabismic children.
According to their study, they reported amblyopia in
80.46% in esotropia and 54.40% in exotropia. Matsuo T,
Matsuo C have reported in their study high prevalence
of amblyopia in school age children but according to
their study strabismic amblyopia was more common in
intermittent exotropia.17 Ahmad-M, Iqbal S, Jhangir N,
have reported in their study on patients of strabismic
amblyopia. According to their study 71.79% patients
with strabismus had amblyopia and in esotropia the
amblyopia was more prevalent-as well as more dense
than exotropia.18 Our study is being supported by results of other national and international studies. Sethi
S has reported amblyopia in 55% strabismic patients.19
Wood Ruff etal has reported in their study that 57%
amblyopia was due to strabismus.
CONCLUSION
Strabismus and amblyopia are common ocular
problems in children. Their identification and diagnosis is necessary in early life which is very sensitive
stage in children. A comprehensive screening program
should be formulated and applied for management.
All children in play group or on entry into school may
be necessarily examined to give them rid of their problems of amblyopia and strabismus.
REFERENCES
1.
CarltonJ, KarnonJ, Czoski-Murray C, Smith KJ, MarrJ. The clinical effective and cost-effectiveness of screening programs for
ambly­opia and strabismus in children up to the age of 4-5
years; a systemic review and economic evaluation. Health Technol Assess. 2008;12(25):1-194.
2.
Scheiman M, Wick B. Clinical Management of Binocular Vision:
Heterophoric Accommodative and Eye Movement Disorders.
Ophthalmology Update Vol. 13. No. 2, April-June 2015
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Philadelphia: Lippincott Williams & Wilkins; 2008. p. 325-244.
Greeberg AE ,Mohney BG etal.Incidence and types of childhood esotropia.A population based study.Ophthalmology
2007;114:170-4.
Rodriguez MA,Castro GM.Visual health of school children in
Medellin,Antioquia Colombia{in Spanish}Bol Oficina Sanit Panam 1995;119:11-4.
Committee on Practice and Ambulatory Medicine Section on
Ophthalmology, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and
Strabismus, American Academy of Ophthalmology: Eye examination in infants, children, and young adults by pediatricians. Organizational princi­ples to guide and define the child
health care system and/or improve the health of all children.
Ophthalmology (2003) 110: 860-865.
Matsuo T, Matsuo C, Matsuoka H and Kio K: The detection of
strabismus and amblyopia at 1.5- and 3-year-old children by
pre­school vision-screening program in Japan. Acta Med Okayama (2007)61: 9-16.
Shah MA,Khan.S,Mohammad.S.Presentation of childhood
squint.J Postgrad Med Inst. Jun 2002; 16:206-10.
Mohney BC,Greenberg AE,Diehl NN.Age at strabismus diagnosis in an incidence cohort of children.Am J Ophthalmol
2007;144:467-9.
Graham PA. Epidemiology of strabismus.Br J Ophthalmol
1974;58:224-31.
Sala NA. Amblyopia and Strabismus. Pa Med. 1996; 99:63-6.
Pediatric Eye Disease investigator group. The clinical profile
of moderate amblyopia in children younger than 7 years Arch
Ophthalmol. 2002; 120:281-7.
Lithander J. Prevalence of amblyopia with anisometropia or
strabismus among school children in the Sultanate of Oman.
Acta Ophthalmol. 1998; 76:658-62.
Shafique MM,Ullah N, Nadeem HB et al.Incidence of Amblyopia
in Strabismic Population.Pak J Ophthalmol 2007,Vol 23 NO 1.
Preslan MW, Novak A. Baltimore Vision Screening Project.
Ophthalmology. 1996;103(l):105-9.
Preslan MW, Novak A. Baltimore Vision Screening Project.
Phase 2. Ophthalmology. 1998;105(1):150Kvarnstrom G, Jakobsson P, Lennerstrand G. Visual screening of Swedish children: an ophthalmological evaluation.
Acta Ophthalmol Scand. 2001; 79(3):240-4.
Matsuo T,Matsuo C .The prevalence of strabismus and amblyopia in Japanese elementary school children.Ophthalmic Epidemiol.2005 Feb:12(1):31-6.
Ahmed M,Iqbal S,Jehangir N. Amblyopia in strabismic children .Ophthalmology Update .Jan-March 2012 Vol.NO I.
Sethi S ,Hussain I, SethiMJ. Causes of amblyopia in children coming to ophthalmology OPD KTH Peshawar. JPMA
2008;58:125.
81
ORIGINAL ARTICLE
Tuberous Sclerosis Complex
Hussain Ahmad
Hussain Ahmad Khaqan FCPS, FRCS1, Farrukh Jameel MBBS2
Hadia Jabeen MBBS3, Muhammad MBBS4, Usman Imtiaz MBBS5
INTRODUCTION
Tuberous sclerosis complex (TSC) is an autosomal dominant neuro-cutaneous disease (phacomatosis)
with variable clinical manifestations.1 The incidence of
the disease is approximately 1/6000- 1/10000.2,3 Diagnosis is based on clinical and para-clinical criteria defined by the tuberous sclerosis consensus conference
in 1998. There are two groups of symptoms including
major and minor criteria. The major criteria consist of:
Facial angio-fibromas or forehead plaques, Non-traumatic ungula or periungual fibroma, Hypo-pigmented
macules (more than 3), Shagreen patch, Cortical tubers,
Sub-epandymal nodules, Sub-epandymal giant cell astrocytoma, Multiple retinal nodular hamartomas, Cardiac rhabdomyoma, Lymphangio-myomatosis and renal angio-myolipoma.
Patient
A
Age/sex
8/M
V/A
6/12 , 6/6
Anterior Segment
Unremarkable
Posterior Segment
OU Retinal Astrocytomas
Systemic manifestations
•
•
•
•
Ash leaf spots
Sub ungal hemartoma
Small angio-lipomas over both kidneys
Multiple calcified foci in subependymal region
• Sebaceous adenomas
The minor criteria include: Dental Pits (more than 14),
Hamartomatous rectal polyps, Bone cysts, Cerebral
white matter radial migration lines, Non-renal hamartomas, Retinal achromatic patch, Confetti skin lesions,
Multiple renal cysts. When there are two major criteria
or one major and two minor criteria the diagnosis is established as definite TSC. The term probable TS is used
Consultant Ophthalmologist & Retinal Surgeon, Lahore General Hospital / PGMI, Lahore. 2,3,4Postgraduate Trainees, Lahore General Hospital / PGMI, Lahore. 5Resident Alshifa Trust Eye Hospital, Rawalpindi
1
Correspondence: Dr. Hussain Ahmad Khaqan Department of Ophthalmology, Lahore General Hospital / PGMI, Lahore. House No. 87,
Eden Canal Villas, Canal Bank Road, Thokar Niaz Baig, Lahore.
E-Mail:drkhaqan@hotmail.com,Tel.+92-42-37498314
Cell: +92-300-4270233, Fax:+92-42-7223039
Received: December 2014
82
when one major and one minor criteria are detected (2).
Only one major feature or two or more minor criteria
without any major feature mentions the possibility of
tuberous sclerosis.2
Ocular manifestations of TSC including retinal
hamartomas occur in less than 50% of the patients and
are bilateral in one third of the cases. There is no correlation between age and ocular manifestations.2
Case Series:
Case series identified 5 eyes of three patients over
the period of 3 months from May 2013 to July 2013 (age
range 8 years to 42 years). 1 of the patients was referred
from neurosurgery department of Lahore General
Hospital, after complaining of seizures and decrease
vision, that patient had retinal Astrocytomas and systemic findings sebaceous adenomas, ash leaf spots, sub
Accepted: January 2015
B
C
42/F
12Y/M
6/6, 6/6
6/6, 6/6
Unremarkable
Unremarkable
OD Retinal Astrocytomas
OD Retinal Astrocytomas
Un-remarkable
Un-remarkable
ungal hemartoma, small angio-lipomas over both kidneys, multiple calcified foci in sub-ependymal region
on initial examination. 1 patient was the sibling of the
patient who also had retinal Astrocytomas. 3rd patient
was the mother of the patients who had right retinal
astrocytomas
Table 1 summarizes the case of all three patients with
their age, visual acuity on presentation, initial investigations, examination findings, fundus findings
Patient “ A”
A child 8 years/male, presented in Eye-OPD on
1st July, 2013 for the assessment of fundus, referred by
some neuro-physician. He has history of fits for 2years
and spontaneous muscular spasm over Left arm, for
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
family history of fits. He has 3 siblings (all boys). Both
of his parents were alive and healthy
Ocular Examination
V/A 6/12, 6/6
Anterior segment was normal
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
Sebaceous adenomas
Patient “B”
This patient was the mother of patient “A”she was
42 y of age. She was screened for any signs and symptoms of tuberous sclerosis. after examination she was
found having right retinal astrocytomas without any
systemic manifestations
Left fundus
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
83
Tuberous Sclerosis Complex
DISCUSSION
3 patients were evaluated for Tuberous Sclerosis
manifestations(ocular and systemic). 2 patients were
male siblings and 1 was the mother. only 1 patient
showed both ocular and systemic features. 2 patients
showed only Ocular features. this shows strong inheritance pattern and that the Tuberous Sclerosis complex
does not necessarily shows systemic manifestations.
CONCLUSION
Tuberous Sclerosis although is a rare having vari-
able ocular and systemic manifestations
REFERENCES
1.
Seyyed Hassan TONEKABONI, MD,1 Seyyed Hassan Tonekaboni, MD,1 ParvizTousi, MD,2 Ahmad Ebrahimi. Clinical and
Para clinical Manifestations of Tuberous Sclerosis ran J Child
Neurol. 2012 Summer; 6(3): 25–31
2.
Staley BA, Vail EA, Thiele EA. Tuberous sclerosis complex:
diagnostic challenges, presenting symptoms, and commonly
missed signs. Pediatrics. 2011 Jan;127(1):e117–25
3.
Thiele EA, Korf BR. Phakomatoses and allied conditions. In:
Swaiman KF, Ashwal S, Ferriero DM, editors. Swaimans pediatric neurology. 5th ed. China: Elsevier Saunders; 2012. pp.
504–9.
IMPORTANT NOTE
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:
Sr. No
84
Names
Designation
Area
Mobile
1
Amir Zaib
Divisional Manager
Peshawar Div.
0302-5551659
2
Waqas Majeed
Divisional Manager
Rawalpindi Div.
0302-5551817
3
Waseem Ejaz
Regional Sales Manager
Lahore Div.
0300-8494327
4
S. Arshad Ali
Sr. Divisional Manager
Faisalabad Div.
0302-5552024
5
Niaz Shaikh
Sr. Divisional Manager
Multan Div.
0302-5552041
6
Khalid Mehmood
Sr. Divisional Manager
Karachi Div.
0303-7770670
Ophthalmology Update Vol. 13. No. 2, April-June 2015
ORIGINAL ARTICLE
Association of Anemia with Diabetic Retinopathy
in Patients with Type II Diabtese Mellitus
Mohammad Kashif
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).
INTRODUCTION
Diabetes Mellitus (DM) is one of the leading causes of morbidity and mortality around the globe and is
responsible for 3.8 million deaths per year.1 Its prevalence has shown an exponential rise worldwide in the
last two decades from 30 million cases in 1985 to 177
million in 2000.2 The estimated number of patients with
DM worldwide for 2010 was 285 million which is projected to increase to 439 million by 2030.3 The International Diabetes Federation (IDF) ranks Pakistan 7th in
the list of prevalence of DM.1 At least 171 million people worldwide have DM and this figure is likely to be
doubled by the year 2030. About 50% of persons with
DM are unaware of the condition and about 2 million
deaths every year are attributable to this complication
of DM.2 Diabetic mellitus type 2 (T2DM) is characterized by peripheral insulin resistance, impaired regulation of hepatic glucose production and declining ß-cell
Senior Optometrist, Pakistan Institute of Community Ophthalmology Hayatabad Medical Complex, Peshawar. 2Trainee Optometrist
Pakistan Institute of Community Ophthalmology Hayatabad Medical
Complex,Peshawar. 3Eye Specialist, District Head Quarter Hospital,
Nowshera, KPK.
1
Correspondence: Mohammad Kashif MPH. Senior OptometristFaculty Member, Pakistan Institute of Community Ophthalmology Hayatabad Medical Complex, Email: kashifoptom@hotmail.com
Cell: 03339100610
Received: December 2014 Accepted: February 2015
Ophthalmology Update Vol. 13. No. 2, April-June 2015
function, eventually leading to ß-cell failure.
Diabetic Retinopathy (DR) is the most common micro
vascular complication of DM and it remains a leading
cause of legal blindness and visual impairment in the
working-age population in the developed world. There
has been a surge in the T2D-related Diabetic Retinopathy in the last 2 decades, especially in Asian population. Studies using retinal photography consistently
suggested that the prevalence of DR is close to 40%, and
sight-threatening DR (STDR) accounts for 6-8% of all
diagnosed cases.
Diabetic Retinopathy: It is the characteristic group of
lesions found in the retina of individuals who have
DM for several years. It is considered to be the result
of vascular changes in the retinal circulation, a microangiopathy that exhibits features of both micro vascular occlusion and leakage.14 DR is a progressive condition with micro vascular alterations that lead to retinal
ischemia, retinal permeability, retinal neo-vascularization and macular edema. If left untreated patients with
DR can suffer severe visual loss. DR is asymptomatic in
early stages of the disease, but as the disease progresses
symptoms may include blurred vision, floaters, fluctuating vision, distorted vision, dark areas in the vision,
poor night vision, impaired color vision, partial or total
loss of vision. The risk factor that results in development and severity of DR include duration of DM, poor
metabolic control, hypertension, hyperlipidemia, preg85
Association of Anemia with Diabetic Retinopathy in Patients with Type II Diabtese Mellitus
nancy, obesity, smoking, cataract surgery and anemia.16
Anemia in type 2 diabetes mellitus. Anemia, the most
common blood disorder, is more prevalent in persons
with DM than in persons without diabetes. Anemia is
a below normal level hemoglobin in the blood.21 WHO
defines anemia as Hb less than 12g/dl in women and
less than 13g/dl in men. Using this definition, nearly
1 in 4 (23%) patients with Type2DM are anemic. The
prevalence of anemia in DM patients is reported as 1448%.22
Etiology of Anemia in Type 2DM
• Diabetic neuropathy affects the central nervous
systems anemia response.
• Nutritional deficiencies (low levels of iron or low
levels of certain vitamins that body needs to produce Hb and make healthy red blood cells).
• Medications for DM and related conditions.
Anemia is an independent risk factor for the development and progression of cardiovascular complications and heart failure, chronic renal disease and DR
in DM patients.25 Anemia has been associated with the
development and progression of both micro vascular
(i.e.; DR) and macro vascular complications of DM.
Anemia can lead to falsely low HbA1c levels, which
may result in under treatment of hyperglycemia, which
in turn will contribute to the progression of both micro
vascular and macro vascular complications.21 Individuals with anemia were more likely to develop DR than
individuals without anemia, perhaps because of anemia-induced retinal hypoxia. Hypoxia may alter angiogenesis, capillary permeability, vasomotor response,
and retinal cells survival.26
MATERIALS AND METHOD
Study Design: Analytical Observational Case Control
study.
Study Settings: Department of Endocrinology, Diabetes and Metabolic Disease at Hayatabad Medical Complex Peshawar.
Study Duration: Study duration was 4 months (from
1st September to 30th December 2014). And total data
collection time was 2 months from first October to 30
November.
Sample Size Total of 170 Patients. 84 cases and 84 control.
Inclusion Criteria:
• Cases: All Type 2 diabetic patients above age 40,
both male and female, having diabetic retinopathy.
• Controls: All type 2 diabetic patients with the
same age, sex, demographic location to the case
group, and having no DR were included.
Exclusion criteria:
In both cases and controls the following exclusion cri86
teria was applied:
• Patients with history of malignancy, blood loss
during the past three months.
• Hypertension: systolic pressure > 140 mmHg and
diastolic pressure > 90 mmHg.
• Hyperlipidemia: low density lipoprotein LDL >
130 g/dl.
• Poor Diabetic control: Fasting blood sugar FBS >
200mg/dl and Random blood sugar RBS > 250
mg/dl.
• Obesity: body mass index > 30 kg/m2.
• Renal failure: creatinine >1.5 mg/dl.
• Cataract surgery.
RESULTS
In this case control study, 85 diabetic retinopathy
patients (cases) and 85 normal retinal subjects (controls), were analyzed to study the association of anemia
with diabetic retinopathy in type 2 diabetes mellitus.
In the control group there were 34 (40%) males and 51
(60%) females, with a mean age of 53.5± years, duration
of DM 9.98± years, Creatinine 0.93± mg/dl. In the case
group NPDR was present in 43 (50.6%) patients, with
a mean age of 53.4 + 9.0 years,(44.2%) were males and
24 (55.8%) females. PDR was present in 24 (28.2%) patients with a mean age of 54.9+7.4 years, 9 (37.5%) males
and 15 (62.5%) females. DME was present in 18 (21.2%)
patients with a mean age of 51.8+8.0 years, 11 (61.1%)
males and 7 (38.9%) females. By sub categorizing NPDR
group, 14 (32.6%) patients had Mild NPDR, 17(39.5%)
had moderate NPDR and 12 (27.9%) had severe NPDR.
In patients with DME, 3 (16.7%) was had mild DME, 7
(38.9%) moderate DME, 8 (44.4%) severe DME. In the
case group mean duration of DM was 10.7± years and
Creatinine level 0.89 mg/dl. Odd ratio for case and control was calculated by applying Chi-Square test which
was 3.86 at 95% of confidence interval (CI) with a P
value of 0.0001. (p-value of < 0.05 level of significance).
Similarly the Odd ratio for NPDR in case and control
was 3.60 at 95% of CI with a P value of 0.001. Odd ratio
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
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
and 12 (11.1%) in the control group. In the case group
anemia was seen in 11 (32.3%) males and 22 (43.1%) in
females. And 3 (21.4%) in mild NPDR, 5 (29.4%) moderate NPDR, 8 (66.6%) in severe NPDR, 11 (45.8%) in
PDR. In DME anemia was present in 1 (33.3%) mild
DME, 2 (28.5%) moderate DME, 3(37.5%) severe DME.
The mean hemoglobin level in patients with PDR was
9.3+0.3, lower than mild to moderate NPDR (10.8+1.3),
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,
11.2+ 2.1 in severe DM.
Table- : Anemia in Patients with
Diabetic Retinopathy and Normal Retinal Subjects
Table- : Anemia and Type of Diabetic Retinopathy
Type of Diabetic Retinopathy
Anemia
Total
NPDR
16 (37.2%)
43
PDR
11 (45.5%)
24
6 (33.3%)
18
33
85
Anemia
Cases
Control
Total
DME
Present
33
12
45
Total
Absent
52
73
125
Total
85
85
170
Odd Ratio at 95% of CI=3.8 P value = 0.0001
Table- : Anemia in Patients
with NPDR and Normal Retinal Subjects
Anemia
Case
Control
Total
Present
16
12
28
Absent
27
73
100
Total
43
85
128
Odd Ratio at 95% of CI = 3.60, P value = 0.001
Table- : Anemia in Patients
with PDR and Normal Retinal Subjects
Anemia
Case
Control
Total
Present
11
12
23
Absent
13
73
86
Total
24
85
109
Odd Ratio at 95% of CI = 5.14, P = 0.001
Table- : Anemia in Patients
with DME and Normal Retinal Subjects
Anemia
Case
Control
Total
Present
6
12
18
Absent
12
73
85
Total
18
85
103
Odd Ratio at 95% of CI= 3.04 P = 0.001
Ophthalmology Update Vol. 13. No. 2, April-June 2015
DISCUSSION
Diabetic Retinopathy is a major cause of blindness
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 severe 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 retinal subjects (controls). DM patients with anemia were
2.4 times more likely to develop DR. Anemia was observed 45.9% in cases and 26.1% in controls and was 43
% in mild to moderate NPDR, 53% in severe NPDR and
PDR. The mean hemoglobin level in controls was higher (12.73+1.38g/dl) than patients with mild and moderate 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 respectively. Similarly, in our study DM patients with anemia
were 3.8 times more likely to develop DR. Anemia was
38.8% in cases and 11.1% in controls and 21.4% in mild
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
receptively.
As in the study conducted in Iran, diabetic maculopathy (DME) was not included, no association was
found between anemia and DME. While in our study
there was a significant association between anemia and
DME with an odd ratio of 3.04. The Hb level was lower 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
of insulin was higher 7 (8.2%) in cases than controls 6
87
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
there was also no association of treatment of DM and
insulin was higher (20.5%) in the case group compared
to the controls (11%).29
Qiao et al. in Finland found that the DM patients
with Hb level lower than 12 g/dl had a two-fold higher
prevalence of retinopathy after other known factors
were controlled. It was also found that in patients with
retinopathy, the severity correlated with the severity of
anemia. Among patients who had DR odd ratio of anemia was 5.3 (95% CI,) for severe DR.32 Similarly in our
study it was found that in DM patients anemia was 3.8
times more likely to develop DR and the severity of DR
was correlated with the severity of anemia as odd ratio
for severe retinopathy (PDR) was 5.1 at 95% of CI.
David et al. 1997 in Early Treatment of Diabetic
Retinopathy Study evaluated a progressive increase
in risk for high risk PDR with decreasing Hb and supporting the importance of anemia as a risk factor for
the progression and severity of DR. The etiology and
pathogenesis of anemia in DM patients is multi factorial. Decreased erythropoietin production is an important cause of development of anemia in DM patients.
Chronic hyperglycemia is involved in the pathogenesis
of anemia by means of creating abnormalities in RBCs,
oxidative stress, autonomic neuropathy and renal sympathetic denervation. These conditions put the renal
inerstitium in a hypoxic state and consequently, the
production of erythropoietin by peritubular fibroblasts
is impaired.34
A well-accepted cut-point definition of anemia was
selected in our study for our, namely a hemoglobin <13
g/dl in men and <12 g/dl in women. Our results demonstrated that the presence of anemia is an independent risk factor for DR in the case control study. Subgroup analysis suggested that the prevalence of anemia
in DR patients (cases) in females was higher (43.1%)
than males (32.3%). A study conducted in 2010 by Ranil
PK et al. in India in which same definition was used
to define anemia, Individuals with anemia were 1.80
times more likely to develop diabetic retinopathy than
individuals with no anemia. The prevalence of anemia
was higher in women (26.4%) than in men (10.3%). Men
with anemia, and not women, had 2 times the risk of
developing diabetic retinopathy. While in our study although the prevalence of anemia was higher in females,
but both males and females in cases with anemia were
3.8 times more likely to develop DR.30
In a case control study done by Francisco J et al.
in 2012 there were total 106 T2DM patients in which
Hb was having a significant association with PDR with
odd ratio of 2.43 at 95% of confidence interval (P value
88
of 0.001) and anemia was an important finding in diabetic patients which was a relevant factor related to
the progression of proliferative diabetic retinopathy
(PDR), which can be treated with photocoagulation.31
This study was having similar results to our study in
which hemoglobin level was also having a significant
association with Proliferative DR with an Odd ratio of
5.1 at 95% of CI (P value of 0.0001).
In a study done in 2012 by JO Chung “Associations between hemoglobin concentration and the clinical characteristics of patients with Type 2 diabetes” the
patients with lower Hb concentrations had a longer duration of diabetes, a lower body mass index, and lower
concentrations of total cholesterol, triglycerides, and
low-density lipoprotein cholesterol. They had a higher
prevalence of diabetic retinopathy (DR) and nephropathy. The increased prevalence of diabetic retinopathy
was associated with lower Hb concentrations. These
findings suggested that lower Hb concentrations might
not only be a consequence of diabetes but may also accelerate micro-vascular damage in diabetes mellitus.[36]
While in our study there was no association of duration of DM with hemoglobin level and patients with a
body mass index (obesity) > 30 kg/m2, LDL > 130mg/
dl were excluded in the study. As they were risk factors for DR so were controlled. Patients with creatinine
< 1.5 mg/dl were included in both cases and controls
proving that anemia in DM patients was unrelated to
anemia due to diabetic nephropathy.
Detection of anemia and its treatment is important
in the management of diabetic retinopathy. In those
patients who had both anemia and diabetes mellitus,
Friedman and associates reported that treatment with
erythropoietin was correlated with substantial resolution of macular hard exudates. The improved Hb
concentration with therapy of anemia improves tissue
oxygenation and may result in reduced VEGF production, which improves the hyper permeability and
reduces the stimulus for neovascularization.41 These
observations suggest that anemia evaluation should be
considered in the routine management of persons with
diabetes and should be treated to minimize the risk of
microvascular complications such as nephropathy and
DR.
CONCLUSION
Diabetic retinopathy is emerging a big public
health problem, affecting working age groups. Our
finding suggests that there was a significant association
between anemia and diabetic retinopathy in Type 2
diabetes mellitus. Anemia was associated with NPDR,
PDR and DME. So it is concluded that anemia is an independent 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
of anemia was higher in females than males having
DR., and was also higher in patients with DR who were
using both oral hypoglycemic medications and insulin
together. Evaluation and treatment of anemia should
be a part of the follow up visits of DM patients. Further
studies about the effect of anemia treatment on the severity of diabetic retinopathy are recommended.
REFRENCES
1.
International Diabetes Federation: The Diabetes Epidemic Is
Out of Control [online]. October 20, 2009 [cited 30/12/2014].
Available at http://asweetlife.org/feature/idf-the-diabetesepidemic-is-out-of-control/.
2.
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence
of diabetes: estimates for the year 2000 and projections for 2030.
Diabetes Care. 2004; 27: 1047–1053.
3.
Sivaprasad S, Gupta B, Evans J et al. Prevalence of Diabetic
Retinopathy in Various Ethnic Groups: A Worldwide Perspective. SurvOphthalmol. 2012; 57(4): 347 70.
4.
JB Brown, KL Pedula, KH Summers. Diabetic Retinopathy
Contemporary Prevalence in a Well-Controlled Population.
Diabetes Care, 2003; 26: 2637-2942.
5.
Thomas, M., Tsalamandris, C et al. Anaemia in Diabetes: An
Emerging Complication of Micro vascular Disease. Current
Diabetes Reviews. 2005; 1: 107-126.
6.
Diabetic Retinopathy - Asia Pacific - American Academy of
Ophthalmology [online]. November 2013 [cited on 21/9/2014].
Available from http://one.aao.org/topic-detail/diabeticretinopathy--asia-pacific.
7.
Vision 2020 – World Health Organization [online]. December
2006 [cited on 20/12/2014]. Available at www.who.int/blindness/Vision2020_report.pdf.
8.
Mahar PS, Awan MZ, Manzar N, Memon MS. Prevalence of
Type-II Diabetes Mellitus and Diabetic Retinopathy [online].
2010 [cited on 30/12/2014]. Available at http://www.atlas.idf.
org/ index1397.html.
9.
Jadoon MZ, Dineen B, et al. Prevalence of blindness and visual
impairment in Pakistan: the Pakistan national blindness and
visual impairment survey. Invest Opthalmol Vis Sci. 2006;
47:4749-55.
10. Qayyum AL, Amir Babar AM, Das G. Prevalence of diabetic
retinopathy in Quetta, Balochistan. Pak J Ophthalmol. 2010;
26(4): 187–192.
11. Shaikh MA, Gillani S, Yakta D. Frequency of diabetic retinopathy in patients after ten years of diagnosis of type 2 diabetes
mellitus. Journal of Ayub Medical College Abbottabad. 2010;
22(3): 158–160.
12. Khan AJ. Prevalence of Diabetic Retinopathy in Pakistan subjects. A pilot study. J Pak Med Assoc.1991; 41: 49.
13. Diabetic Statistics in Pakistan [online]. May 8, 2013 [cited
30/12/2014]. Available at http://diabetespakistan.com/treatment/2013/05/08/diabetes-statistics-in-pakistan.
Ophthalmology Update Vol. 13. No. 2, April-June 2015
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
Diabetic Retinopathy Guidelines- International Council of
Ophthalmology. [online]. 2012 [30/12/2014].
Available on www.icoph.org/dynamic/attachments/diabeticretinopathy.pdf.
Wu L. Loaiza PF et al.Classification of diabetic retinopathy and
diabetic macular edema. World Journal of Diabetes. December
15, 2013; 4(6): 290-294.
Kanski JJ, Bowling B. Clinical Ophthalmology and Systematic
Approach. Edition 7th. Elsevier limited China: Saunders. 28 April
2011; 536.
Kanski JJ, Bowling B. Synopsis of Clinical Ophthalmology.
Third edition. Elsevier limited China: 2013; 244-246.
Gupta V, Gupta A, Dogra MR, Singh R. DIABETIC RETINOPATHY atlas and text. First edition. New delli: 2007; 31-107.
ICO Guidelines for Diabetic Eye Care – International Council of
Ophthalmology [online]. February 2014 [cited on 30/12/2014].
Available at http://www.icoph.org/downloads/ICOGuidelinesforDiabeticEyeCare.pdf.
International Clinical Diabetic Retinopathy Disease Severity
Scale – American Academy Of Ophthalmology [online]. October 2002 [cited on 30/12/214]. Available at one.aao.org/asset.
axd?id=4b0447c9-24c6-411e-a888-3081553693d2.
Thomas MC, MacIsaac RJ, Tsalamandris C, et al. Unrecognized
anemia in patients with diabetes: a cross-sectional survey. Diabetes Care. 2003; 26(4): 1164-9.
WHO - Iron deficiency anaemia: assessment, prevention, and
control [online]. 2001 [cited 30/12/2014].
Available at www.who.int/nutrition/publications/micronutrients/anaemia
Recognizing Anemia in People with Diabetes [online] .March
11, 2009 [cited 24/9/2014].
Available at http://www.anemia.org/patients/feature-articles/content.php?contentid=000367.
Conway BN, Miller RG, Klein R, Orchard TJ. Prediction of
proliferative diabetic retinopathy with hemoglobin level. Arch
Ophthalmol. 2009;127:1494–9.
Deray G, Heurtier A, Grimaldi A, Launay Vacher V, Isnard
Bagnis C. Anaemia and diabetes. Am J Nephrol. 2004;24:522–6.
Irace C, Scarinci F, Scorcia V, et al. Association among low
whole blood viscosity, haematocrit, haemoglobin and diabetic retinopathy in subjects with type 2 diabetes. Br J Ophthalmol.2011; 95: 94–8.
Maccuish AC. Early detection and screening for diabetic retinopathy. Eye. 1993; 7: 254-259.
Congdon NG, Friedman DS, Lietman T. Important causes of
visual impairment in the world today. Journal Of The American Medical Association. 2003; 290 (15): 2057–2060.
Bahar A, Kashi Z, Ahmadzadeh Amiri A et al. Association
between diabetic retinopathy and hemoglobin level. Caspian
Journal of Internal Medicine.2013; 4(4): 759-762.
Rani PK, Raman R, Rachepalli SR. Anemia and Diabetic Retinopathy in Type 2 Diabetes Mellitus. J Assoc Physicians India.
FEBRUARY 2010; 58: 91-4.
diabetic microcirculatory disease? Lancet. 1977; 2: 789–91.
89
ORIGINAL ARTICLE
Laal Mohammad
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
ABSTRACT:
Objective: To find out control of intra ocular pressure after cataract extraction with posterior chamber intraocular lens implantation 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 antiglaucoma 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 patients 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 extracapsular 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
Chamber(PC).
INTRODUCTION
Cataract is considered to be the most significant
cause of blindness globally as well as territorially.1,2
Gifford described phacomorphic glaucoma as a separate entity for the first time in 1900.3 He attributed it
to hypermature cataract. In phacomorphic glaucoma,
the lens blocks the forward flow of aqueous humor
through the pupil resulting in rise of IOP. This classically occurs in large intumescent cataract which is then
named as phacomorphic glaucoma. This lens induced
glaucoma is a preventable and a treatable disease if
managed at proper time. This condition still exists in
the world. Phacomorphic glaucoma is due to lack of
awareness of cataract and delayed surgical interventional removal. It is normally due to wrong concept
that cataract should be mature at the time of surgery,
lack of need for better vision, concurrent systemic diseases , old age, ignorance and economic constraints are
1
Prof. of Ophthalmology, 2Associate Prof. of Ophthalmology, 3Ophthalmologist, KMU Institute of Medical Sciences, Kohat
Correspondence: Professor Lal Mohammad Department of Ophthalmology, KMU Institute Of Medical Sciences, K.D.A Kohat
Cell: 0300-5961577, E-Mail: malamktk@gmail.com
Received: January 2015
90
Accepted: February 2015
other reasons that the patients avoid treatment.4 Different studies have reported that in subcontinent countries
like India, the incidence of intumescent cataract leading
to phacomorphic glaucoma is more in comparison to
western world.5 Cataract extraction is the only treatment of phacomorphic glaucoma. But before surgery
IOP is being lowered down to a safe level with medication to prevent glaucoma related problems. This study
was done to find out the IOP control after cataract extraction with PC- IOL.
MATERIALS AND METHODS
This retrospective study was conducted in KDA
Teaching Hospital Kohat from January 2009 to December 2013 with the objective to find out IOP control after
cataract extraction with PC-IOL in patients of phacomorphic glaucoma. Diagnosis of phacomorphic was
made when patients presented with symptoms of pain,
redness of involved eyes, headache and above normal
IOP, shallow anterior chamber and intumescent cataract. Proper proforma was designed for documentation of clinical findings of patients, time and duration of
presentation on arrival. IOP was checked with Perkin’s
Tonometer and visual acuity was recorded. Total 48
patients were selected out of which 22 (45.83%) were
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
years. Duration of the symptoms were recorded. (Table-II)
All the patients IOP were controlled with mannitol, systemic carbonic anhydrase inhibitor and topical antiglaucoma medicine. Steroid/antibiotic topical
drops were also given to the patients to control inflammation for 5-7 days preoperatively. All the patients
were operated by conventional extra capsular cataract
extraction with PC- IOL implantation. Those patients
with preoperative visual acuity of no perception of
light were excluded from the study. After surgery patients were put on steroid/antibiotic topical drops for
three weeks and pain killer for 5 days. No antiglaucoma medications were prescribed postoperatively. IOP
was checked after one week and one month.
RESULTS
On presentation, preoperative IOP of all patients
was in range of 31 mmHg to 48 mmHg with mean IOP
of 38.8 mmHg. Post operative IOP after one week was
in range of 12 to 22 mmHg with mean IOP of 15.91
mmHg. After one month post operative IOP was in the
range of 12-20 mmHg with mean IOP of 15.52 mmHg.
(Table III)
Table-I: Showing gender distribution.
Gender
No of Patients
%age
Male
22
45.83
Female
26
54.16
Table-II: Duration of presentation
Duration
No of patients
%age
0 -3 days
27
56.25
4 -7 days
15
31.25
8 -14 days
06
12.50
Table-III: Preoperative and postoprtative IOP
IOP
Range in mmHg
Mean in mmHg
Preoperative
31—48
38.8
Postoperative One week
12—22
15.91
Postoperative One month
12—20
15.52
DISCUSSION
Intumescent cataract is the main cause of pupillary block phacomorphic glaucoma resulting in high
IOP with damage to the Optic nerve. After control of
preoperative IOP the patients are operated for cataract
extraction, the obstruction to the out flow of aquous
humor is removed and there is drastic fall in IOP and
the patients do not need any antiglaucoma therapy.
The same statement is true as observed in our study
in which preoperative mean IOP 38.8 mmHg dropped
Ophthalmology Update Vol. 13. No. 2, April-June 2015
down to postoperative mean IOP 15.52 mmHg. There
are many national and international studies showing
similar results. Mandal AK,Gothwal UK have reported
IOP control in normal level in all patients operated for
phacomorphic glaucoma.6 Rajal AP, Karki DB reported IOP control after cataract surgery in phacomorphic
glaucoma to be from 14 – 22 mmHg in all patients. In
their study female patients were more than male as in
our study.7 Payal Gupta study demonstrates post operative IOP to be lower than 20 mmHg in all phacomorophic glaucoma patients without postoperative
antiglaucoma medicine.8 Sing G and Vankatesh et al
studies also reported post operative IOP control of 20
mmHg or less in all patients.9,10 Mohinder Singh, Hassan Al Arrayyed studies reveal IOP control of below 21
mmHg in all patients like in our study. However, the
age of patients with phacomorphic glaucoma were different.11
R Ramekrishanan, Davendra Maheshwari et al
conducted a study of IOP control in phacomorophic
glaucoma in 74 patients. Postoperative IOP was control and below 20 mmHg in all patients with out antiglaucoma therapy.12 They used sutureless surgery
technique so it is clear that IOP control in phacomorphic glaucoma does not depend upon the method used.
Nithisha TM, Mallikarjun, Salagar reported that 28% of
phacomorophic glaucoma patients had postoperative
IOP of more than 20 mmHg which is contradictory to
our study. Probably this variation may be due operation complication.13 PS Mazhar, M Amin Shahzad have
reported in their study 3.6% of all glaucoma was phacomorphic needed urgent control of IOP and removal of
lens.14­This ratio is less as compared to other study.
CONCLUSION
Phacomorphic Glaucoma is a devastating ocular
condition with high IOP. If treated early with cataract extraction and implantation of PC-IOL, pupillary
block will be removed and there is significant fall in
IOP within normal range. The patients do not need antiglaucoma therapy post operatively. Therefore public
awareness programs may be carried out through print
and electronic media and public gatherings to get rid of
this problem.
REFERENCES
1.
Thulasiraj RD, Rahamathulla R, Saraswati A, Selvaraj S, Ellwein LB. The Sivaganga eye survey: I. Blindness and cataract
surgery. Ophthalmic Epidemiol. 2002;9:299-312.
2.
Thylefors B, Negrel AD, Pararajasegaram R, Dadzie KY. Global
data on blindness. Bull World Health Organ.1995;73;115-21.
3.
Duke-Eder S. System of Ophthalmology. Vol. XI: Diseases of
the lens and Vitreous; Glaucoma and Hypotony. St. Louis: CV
Mosby 1969; 662-3.
4.
Tomey KF, al-Rajhi AA. Neodymium: YAG laser iridotomy in
the initial management of phacomorphic glaucoma. Ophthalmology. 1992;99:660-5.
91
Intraocular Pressure Control after Cataract Extraction with Posterior Chamber Intraocular Lens Implantation in Phacomorphic Glaucoma
5.
6.
7.
8.
9.
10.
Lowe RF. Angle closure glaucoma and cataract East. Arch Ophthalmol. 1973;! :80-3.
Mandal AK, Gothwal VK. Intraocular pressure control and
visual outcome in patients with phacolytic glaucoma managed
by extracapsular cataract extraction with or without posterior
chamber intraocular lens implantation.Ophthalmic Surg Lasers.1998 Nov;29(11):880-9.
Rijal AP, Karki DB l. Visual outcome and IOP control after cataract surgery in lens induced glaucoma. Kathmandu University
Medical Journal(2006)Vol,4,No1, Issue 13,30-33.
Gupta P, Bhagotra S, Prakash S. Pattern and Visual Outcome in
Lens Induced Glaucoma.JK Science Vol 14 No 4 Oct-Dec 2012.
Singh G, Kaur J, Mall S. Phacolytic glaucoma-Its treatment by
planned ECCE with PC IOL implantation. Ind J Ophthalmol
1994; 42:145-47.
VenkateshR, TanCS, Kumar TT, Ravindran Rd. Safety & effi-
11.
12.
13.
14.
cacy of manual small incision cataract surgery for phacolytic
glaucoma. Br J Ophthalmol 2007; 91 (3): 269-70.
Singh M, Al-Arrayyed H, Krishnan R. Intraocular Lens Implantation in Phacomorphic Glaucoma.Bahrain Medical Bulletin Vol 24,NO 3 Sep 2002.
Ramakrishanan R, Maheshwari D, Kader MA, Singh R, Pawar N, and Bharathi MJ. Visual prognosis, intraocular pressure
control and complications in phacomorphic glaucoma following manual small incision cataract surgery. Indian J Ophthalmol. 2010 Jul-Aug; 58(4): 303-306.
Nithisha TM, Salagar M, Hiremath LD, Selvan VT, Hiremath
DA. A non randomized clinical study of posterior chamber IOL
implantation in lens induced glaucoma. Medica Innovatica,
Dec 2014,Vol 3(2).
Mahar PS, Shahzad MA. Glaucoma Burden in a Public Sector
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 V
Rabat, Morocco., Curtesy NEJM issamlalya@yahoo.fr
92
Ophthalmology Update Vol. 13. No. 2, April-June 2015
ORIGINAL ARTICLE
Causes of Low vision and Quality of Life after
Rehabilitation in Children & Adults
Mohammad Kashif
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 Hayatabad Medical Complex during a period of six month from June 2014 to Dec 2014. A total of one hundred and sixty five subjects 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%, corneal 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
INTRODUCTION
Low Vision: a person with low vision is one who
has impairment of visual functioning even after treatment and/or standard refractive correction, and has a
visual acuity of less than 6/18 to light perception, or a
visual field less than 10 degrees from the point of fixation, but who uses, or is potentially able to use, vision
for the planning and/or execution of a task for which
vision is essential.1 Or Low vision is visual acuity less
than 6/18 and equal to or better than 3/60 in the better eye with best correction.1 (WHO)” Functionally, low
Senior Optometrist, Pakistan Institute of Community Ophthalmology Hayatabad Medical Complex, Peshawar. 2Eye Specialist, District Head Quarter Hospital, Nowshera, KPK. 3Lecturer Optometry,
Pakistan Institute of Community Ophthalmology Hayatabad Medical
Complex. 4Orthoptist, Pakistan Institute of Community, Ophthalmology Hayatabad Medical Complex. 5Optometrist, Pakistan Institute of
Community, Ophthalmology Hayatabad Medical Complex peshawar.
1
Correspondence: Mohammad Kashif MPH, Senior Optometrist-Faculty Member, Pakistan Institute of Community Ophthalmology Hayatabad Medical Complex. Email: kashifoptom@hotmail.com
Cell: 03339100610
Received: December 2014
Accepted: February 2015
Ophthalmology Update Vol. 13. No. 2, April-June 2015
vision is characterized by irreversible visual loss and a
reduced ability to perform many daily activities, It is
an important public health problem and provision of
low vision services is one of the priorities in the global
initiative, VISION 2020—The Right to Sight.
Low Vision and Quality of Life: The quality of life of
a person with low vision is always compromised. The
presence of low vision affects functional and social life
of an individual and has a negative effect on physical
and emotional well being and increased emotional distress.2 The provision of low vision services and
use of low vision devices allows people with visual
impairment to use their limited residual vision as optimally as possible.
1.3 ICD-10 Classification of Visual Impairment: “The
world Health Organization ICD-10 (International Classification of Diseases) categories the visual impairment
in to three categories 1: Moderate visual impairment
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
better eye.3”
93
Causes of Low vision and Quality of Life after Rehabilitation in Children & Adults
1.5 Causes of Low Vision: Globally the principal causes
of visual impairment are un-corrected refractive errors
and cataracts, 43% and 33% respectively. Other causes
are glaucoma, 2%, age related macular degeneration
(ARMD), diabetic retinopathy, trachoma and corneal
opacity. A large proportion of causes, 18%, is undetermined. The causes of blindness are cataract, 51%, glaucoma, 8%, AMD, 5%, childhood blindness and corneal
opacities, 4%, uncorrected refractive errors and trachoma, 3%, and diabetic retinopathy 1%, he undetermined
causes are 21%.9(WHO 2010)
naire was administered to every patient on first visit
and after using LVDs.
1.6 Data Management and Analysis: Data were entered
in the register after each low vision day and then entered and analyzed using SPSS version 20. Frequency
tables and cross tables were used.
RESULTS
The study population was divided in to two groups on
the basis of age.
1: Adults
2: Children
Table-1: Age + Gender wise distribution of study population
Global causes of visual
impairment inclusive of blindness, as percentage
Male
95
57.57%
Female
70
42.42%
Adult
102
61.8%
Children
63
38.18%
Total
165
100%
Gender wise Distribution of study population
METHODOLOGY
This study conducted at low vision clinic in Department of Ophthalmology Hayatabad Medical Complex Peshawar, Pakistan. The study sample of 165
patients were thoroughly assessed / examined and
treated by Ophthalmologist. Those patients who did
not achieved visual acuity better than 6/18 after surgical, medical or optical treatment were referred to low
vision clinic. The other sources of referral are patients
referred by ophthalmologist from Tehsil and District
head quarter hospitals from all over the province.
Low Vision assessment: The patients were seen first by
ophthalmologists and then referred to low vision clinic
for assessment, where they are refracted and assessed
for LVDs Optometric examination included detailed
history of the patient, his/ her family history; functional, occupational and clinical assessment. The anterior
and posterior segment examination was performed.
The diagnosis was confirmed by at least one ophthalmologist and one optometrist.
Visual Acuity: Distance visual acuity was measured by
Log MAR chart, near visual acuity was measured William 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 question94
Table-2: Distribution of causes of low
vision among total population
S No
Cause
Number
of Patients
Percentage
1
Retinitis Pigmentosa
23
13.93%
2
Age Related Macular
Degeneration
22
13.3%
3
Aphaki
20
12.12%
4
Stargardts Disease
18
10.9%
5
Corneal Opacity
18
10.9%
6
High Myopia
16
9.69%
Nystagmus
16
9.69%
7
Oculo-cutaneous Albinism
with Nystagmus.
12
7.27%
8
Cong Cataract
8
4.84%
9
Glaucoma
7
4.24%
10
Cone Dystrophy
5
3.03%
11
Total
165
99.9%
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
S No
Cause
Table-6: Categories of Low Vision in Children
Number
of Children
Percentage
S. No
Number
of Patients
Percentage
Moderate visual Impairment
26
41.2 %
Type of Low Vision
1
Stargardts Disease
14
22.22%
1
2
Nystagmus
11
17.4%
2
Severe Visual Impairment
20
31.7 %
Blind or profound Visual
Impairment
17
26.98 %
3
Retinitis Pigmentosa
9
14.28%
3
4
Oculo-cutaneous Albinism
with Nystagmus.
8
12.69%
Total
5
Aphakia
8
12.69%
6
High Myopia
7
11.11%
7
Congenital Cataract
2
3.17%
8
Corneal opacity
2
3.17%
9
Cone Dystrophy
1
1.58%
10
Congenital Glaucoma
1
11
ARMD
0
12
Total
63
Cause
Table-7: Categories of Low Vision in Adult population
S. No
Type of Low Vision
Number
of Patients
Percentage
1
Moderate visual Impairment
41
40.1 %
2
Severe Visual Impairment
36
35.29 %
1.58%
3
Blind or profound Visual
Impairment
25
24.5 %
0%
Total
102
Table: 8 Distributions of Low
Vision Device among the total study population
Table: 4 Distribution of causes
of low vision among Adult population
S No
63
S. No Type of devices
Number
of Children
Percentage
children
Adult
Total
1
Telescope only
35 (55.5%)
15(14.7%)
50(30.3%)
2
Magnifier only
11(17.4%)
43(42.15%)
54(32.7%)
1
Age Related Macular
Degeneration
22
21.56%
3
Both
10(15.8%)
16(15.6%)
26(15.75%)
2
Corneal Opacities
16
15.68%
4
Funda Glasses
9(14.2%)
24(23.5%)
33(20.0%)
3
Retinitis Pigmentosa
14
13.72%
4
Aphakia
12
11.7%
Table-9: Problems during Distance Vision, Mobility
and Lighting among Total Study population before and
5
High Myopia
9
8.82%
after Low Vision Aids
6
Congenital Cataract
6
5.88%
7
Glaucoma
6
5.88%
8
Nystagmus
5
4.90%
9
Oculocutaneous Albinism
with Nystagmus
4
3.92%
10
Stargardts Maculopathy
4
3.92%
11
Cone Dystrophy
4
3.92%
12
Total
102
Categories of Low Vision in study Population: The
World Health Organization Classify the low vision in
to three broad categories on the basis of the best corrected vision.1: Moderate (6/60 < VA < 6/18, 10° < VF
< 20°) 2: severe vision impairment (3/60 < VA < 6/60,
5° < VF < 10°) 3: Blindness or profound vision impairment (VA < 3/60, VF < 5°).
Table-5: Categories of low vision in Total population
S.No
1
2
3
Total
Type of Low Vision
Moderate visual
Impairment
Severe Visual
Impairment
Blind or profound Visual
Impairment
Number
of Patients
Percentage
67
40.60 %
56
33.9 %
42
25.45 %
165
99.9%
Ophthalmology Update Vol. 13. No. 2, April-June 2015
Before LVAs
S.No Categories
After LVAs
Number Percentage Number Percentage
(n)
(%)
(n)
(%)
1
Great
112
68 %
17
10 %
2
Moderate
45
3
None
8
27 %
33
20 %
5%
115
70 %
165
100%
165
DISCUSSION
A group of diseases in either ages and genders
that leads to low vision, affects the overall quality of
life and has profound physical, psychological and social impacts. Our study investigates the major causes
of low vision in both children and adult population,
while most of the studies conducted are only confined
to either adults or children. More over the quality of
life score is measured that shows the affectivity of low
vision services that consequently helps in planning and
development of low vision services. If we look at the results the retinal diseases were commonest among both
adults and children. In retinal diseases the pattern of
diseases was different in two groups. Stargardts maculopathy in which the onset takes place in the first decade of life and is almost untreatable, so it runs throughout the life. The child and/or parents usually noticed
95
Causes of Low vision and Quality of Life after Rehabilitation in Children & Adults
the decrease of vision when the child is admitted in the
school. Nystagmus is the second leading cause among
children that accounts for about 17%, Retinitis pigmentosa 14% and oculo-coetaneous albinism with nystagmus 8%. If we add the nystagmus without albinisim
and with albinism it becomes 25% and becomes the
leading cause of low vision in children. The severity of
the low vision caused by nystagmus is comparatively
lower than retinitis pigmentosa and stargardts disease.
Retinitis pigmentosa was prevalent in both adult and
children but more in adults than in children. The reason
may be that R/P is a progressive disease and some patients do not noticed the deterioration of vision in early
life until it goes on progression and causes much damage to the vision which is then noticed by the patients.
In the case of adults the major cause of low vision observed was age related macular degeneration
(ARMD) which is the disease of old population and
caused by degenerative changes in the retina with
growing age. Its onset takes place after fourth decade
of life. ARMD badly affects the central vision and. Illuminated magnifiers enhance the reading capabilities of
the patients and can improve quality of life by helping
in reading, signing cheques, reading price tags in the
market, needle threading and reading holly Quran.
The second leading cause of low vision among
adult population was corneal opacities 16% R/P and
aphakia 13 and 12% respectively. High myopia was responsible for about 8% in adults. These results are coinciding with the results of the study conducted in the
same center but the target population was only adults.
The study shows that the main causes of visual impairment included nystagmus (15%), Stargardt’s disease
(14%), maculopathies (13%), myopic macular degeneration (11%) and oculocutaneous albinism (7%). The percentages of visually impaired, severe visually impaired
and blind were 33.8%, 27.2% and 39.0% respectively.
A study conducted on the causes of low vision in Mohimbili National Hospital Dar us Salaam Tanzania revealed that among 561 patients, there were 100(17.83%)
patients with low vision. The highest proportion (10.3)
of low vision patients was found among the age group
of 18-27 years age, and a gradual trend of decrease in
low vision patients with increasing age (0.2% in eldest
age group of 78-87 years) was observed. Optic neuropathy was the predominant cause of low vision (47%) in
the study population, followed by ARMD (9%), Retinitis pigmentosa (7%), glaucoma (7%), albinism (7%),
amblyopia (7%), corneal diseases (5%), refractive errors
(4%), diabetic retinopathy (4%) and macular scars (3%).
The severity of the problem was categorized in to
severe, moderate and none. These questions encom96
pass almost all the aspects of quality of life in terms of
vision. The results of the study revealed that in total
population 68% of the population had great problem,
27% had moderate problem while 5% had no problem
with distance vision mobility and lighting before low
devices. After using low vision devices the population
with great problem reduces 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 eg reading, distance equity
etc but still significant amount of population gain a
reasonable score after using LVD,s. In general, optical
devices (including distance or near magnifiers, field
expanders, night-vision aids) are less useful for those
with poorer levels of visual function, and those affected
require environmental modification (e.g., light augmentation, improving mobility). Evidence exists that
low-vision services improve quality of life and mental
state clinical trial evidence of the effectiveness of specific interventions for individuals with FLV is lacking.
A recent Cochrane review concluded that further
research is recommended to compare different types of
low-vision devices as well as to delineate patient characteristics that predict performance. Designing clinical
trials of low-vision interventions is challenging due
to the heterogeneous nature of the causes and consequences of the conditions causing FLV, the wide range
of possible interventions, the fact that interventions
must be tailored to individuals’ needs, and the large
number of possible outcomes research of this kind is
urgently needed in developing counties, as findings
from studies in industrialized countries may not apply
in situations in which the causes and functional visual
needs are quite different.
CONCLUSION & RECOMMENDATIONS
Efforts should be done to reduce the low vision
burden of the diseases which are treatable, genetic
counseling of the families having disease like Retinitis pigmentosa to minimize its occurrence by avoiding
consanguine marriages. Visually impaired children especially with hereditary/congenital ocular anomalies
benefit from refraction and low vision services which
facilitate vision enhancement and inclusive education.
Awareness among eye care professionals should be enhanced, in order to facilitate referral and management
of low vision. Efforts to expand low vision services including making simple, high quality, low cost, Low Vision devices.
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)
None
5
5
GRADING
Moderate
Great
4
3
2
1
4
3
2
1
x
x
n/a
n/a
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. reaching
for a glass)
Seeing steps or curbs
Getting around outdoors (e.g. on uneven pavements)
because of your vision
5
5
5
5
5
5
5
4
4
4
4
4
4
4
3
3
3
3
3
3
3
2
2
2
2
2
2
2
1
1
1
1
1
1
1
x
x
x
x
x
x
x
n/a
n/a
n/a
n/a
n/a
n/a
n/a
5
5
4
4
3
3
2
2
1
1
x
x
n/a
n/a
Crossing a road with traffic because of your vision
5
4
3
2
1
x
n/a
x
x
x
n/a
n/a
n/a
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
How well has your eye condition been explained to you
No
5
5
5
Moderately
4
3
4
3
4
3
Greatly
2
1
2
1
2
1
Well
5
4
3
2
Poorly Not explained
1
x
None
5
5
5
5
5
4
4
4
4
4
Moderate
3
3
3
3
3
2
2
2
2
2
Great
1
1
1
1
1
x
x
x
x
x
n/a
n/a
n/a
n/a
n/a
None
5
5
5
5
4
4
4
4
Moderate
3
3
3
3
2
2
2
2
Great
1
1
1
1
x
x
x
x
n/a
n/a
n/a
n/a
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
cutting)
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
97
Causes of Low vision and Quality of Life after Rehabilitation in Children & Adults
Annexure I: Data Collection Instrument
NAME:
AGE:
SEX:
SERIAL NO:
Occupation:
Address:
Ophthalmology Findings
Right Eye
Left Eye
Cause of Low Vision /Blindness
Distance Visual Acuity
(Without Glasses)
Right Eye
Left Eye
Binocular
Test Used
Distance Visual Acuity
(With Glasses)
Right Eye
Left Eye
Binocular
Test Used
Near Visual Acuity
Right Eye
Left Eye
Test Used
Right Eye
Left Eye
Near Add
Visual Fields
Refraction
Test Used
Low Vision Assessment
Eye Selected
Right Eye
Left Eye
Type of Telescope
Type of Magnifier
Visual Acuity With LVD
Right Eye
Left Eye
Near
Distance
Non-Optical Aid
Right Eye
Left Eye
Action/ Comments
REFRRANCES
1. World Health Organization /International Agency for the Prevention of Blindness. State of the World’s Sight Vision 2020:
The Right to Sight 1999–2005. Geneva, Switzerland: WHO;
2005.
2. Scott IU, Smiddy WE, Schiffman J, Feuer WJ, Pappas CJ. Quality of life of low-vision patients and the impact of low-vision
services. Am J Ophthalmol. 1999;128:54---62.
3. World Health Organization. ICD-10 International Statistical
Classification of Diseases and Related Health Problems, 10th
Revision In: Johnson GJ, Minassian DC, Weale R, Eds. The Epidemiology of Eye Disease. London: Chapman & Hall Medical;
1998:8–30.
4. Dineen B, Bourne RR, Jadoon Z, et al. Causes of blindness and
visual impairment in Pakistan. The Pakistan national Blindness
andVisual Impairment Survey.Br J Ophthalmol.2007; 01:1005–
98
1010.
World Health Organization/Global Data on Visual impairment 2010.
6. Pararajasegaram R. VISION 2020 - The Right to Sight: from
strategies to action (editorial). Am J Ophthalmol. 1999; 128: 35936.
7. Resnikoff S. Pacolini D. Etya’ale D, et al. Global data on visual
impairment in the year 2002. Bull World Health Organ. 2004;
82: 844-851
6. Pollard.T, Simpson.J,Lamoureux.E and Keeffe.J. Barriers to accessing low vision services. Ophthal Physio Opt 2003;23: 321327.
9. World Health Organization/Global Data on Visual impairment 2010.
10. mshah et al causes of low vision in children.
11. World Health Organization. Consultation on Development of
5. Ophthalmology Update Vol. 13. No. 2, April-June 2015
Causes of Low vision and Quality of Life after Rehabilitation in Children & Adults
12. 13. 14. 15. Standards for Characterization of Visual Loss and Visual Functioning. 2003; WHO Geneva, Switzerland. PBL/03.91
‐ Resnikoff S, Pascolini D, Etya’ale D, et al. Global data on visual
impairment in the year 2002. Bull World Health Organ
World Bank. World Bank list of economies (July 2009) h p://
siteresources.worldbank.org/DATASTATISTICS/ Resources/ClASS.xls. date accessed March 15, 2010.
‐Organisa on for Economic Co‐opera on and Develop‐ ment.
Policy Briefs available at h p://www.oecd.org/ publica ons/
Policybriefs. date accessed May 1, 2010.
Dineen, Bourne, Ali, et al, Prevalence and causes of blindness
and visual impairment in Bangladeshi adults: results of the National Blindness and Low Vision Survey of Bangladesh. Br J
Ophthalmol 2003;87:820–828.
16. YemaneBernahe et al. prevalence and causes of blindness and
low vision in Ethiopia, Ethiop. J. Health Dev. 2007; 21(3).
17. Keeffe J. Vision Assessment and Prescription of Low Vision Devices. J Comm Eye Health 2004;17: 3-4.
18. Best AB. The management of low vision in Children. Br J Ophthalmol. 1995;13: 65-68.
19. Hornby SJ, Adolph S, Gothwal VK, et al. Evaluation of children
in six blind schools of Andhra Pradesh. Indian J Ophthalmol.
2000;48: 195-200.
20. Rahi JS, Sripathi S, Gilbert CE, et al. The importance of prenatal
factors in childhood blindness in India. Dev Med Child Neurol.
1997;39 : 449-55.
18th Annual Islamabad
Congress of Ophthalmology
Will be held
at Bhurban (Murree) from
24-26 April 2015
Please Contact: Dr. Waheed Afzal, President
OSP Federal Secretariat
E.mail: ospfederaleye@gmail.com
Phone: 03335153266
Ophthalmology Update Vol. 13. No. 2, April-June 2015
99
ORIGINAL ARTICLE
The Efficacy of Limbal Based Conjunctival
Flap in Patients Undergoing Trabeculectomy
with Intra-operative Mitomycin C
Hasan Yaqoob
Hasan Yaqoob FCPS, FRCS1, Mohammad Idris FCPS2
Zubairullah Khan FCPS3, Zubairullah Khan FCPS4, Mudasser Hussain Turi FCPS5
Naseer Ahmad DOMS5, Bilqees Hassan MBBS6
ABSTRACT
Objective: To determine the efficacy of limbus based conjunctival flap in patients undergoing trabeculectomy with intraoperative 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 postoperative 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.
INTRODUCTION
Glaucoma is characterized by progressive loss of
retinal ganglion cells leading to characteristic visual
fields defects and optic nerve head cupping and pallor1. It is an optic neuropathy secondary to various risk
factors including increased IOP.
Glaucoma may be (a) congenital or (b) acquired.
Further sub-classification into open-angle and angleclosure type is based on the mechanism by which aqueous outflow is impaired. The glaucoma may also be (a)
primary or (b) secondary depending on the presence or
absence of associated risk factors. In primary glaucoma
there is no associated ocular disorder while in secondary glaucoma a recognizable ocular or non-ocular disConsultant, Ophthalmology Unit, North West General Hospital,
Peshawar, KPK. 2Medical Officer, Ophthalmology UNIT, PGMI, LRH
Peshawar. 3Consultant, Ophthalmology, Mission Hospital, Peshawar,
KPK. 4Associate Ophthalmologist, LRBT Free Eye Hospital, Mandra,
Rawalpindi. 5Trainee Medical Officer, Hayatabad Medical Complex,
Peshawar. 6Medical Officer Pakistan Institute of Ophthalmology,PICO,
Peshawar
1
Correspondence: Dr. Hasan Yaqoob FCPS, FRCS Consultant,
Ophthalmology UNIT, North West General Hospital, Phase V,
Hayatabad, Peshawar, KPK. Pakistan. Cell: 00992-0345-2565959,
Email drbilqees@gmail.com
Received: December 2014
100
Accepted: January 2015
order alters aqueous outflow. Secondary glaucoma may
be acquired or developmental and of the open-angle or
angle-closure type.
Secondary open-angle glaucoma may be:
1. Pre-trabecular like neovascular glaucoma.
2. Trabecular like pigmentary glaucomas, red cell
glaucomas, ghost cell glaucomas, phacolytic glaucomas, pseudoexfoliative glaucomas and posttraumatic angle recessive glaucoma etc.
3. Post-trabecular in which aqueous outflow is impaired by elevated episcleral venous pressure due
to carotid-cavernous fistula, Sturge-Weber syndrome and obstruction of superior vena cava.
Secondary angle-closure glaucoma may be due to
posterior forces which push the peripheral iris against
the trabeculum (iris bombe due to seclusion-pupillae)
or anterior forces which pull the iris over the trabeculum by contraction of inflammatory or fibrovascular
membrane (e.g. late neovascular glaucoma).
Patients present with a variety of signs and symptoms like pain, watering, dimness of vision, headache,
nausea and vomiting depending on the nature of glaucoma. Therefore, slit-lamp biomicroscopy, fundoscopy,
tonometry, gonioscopy and perimetry is mandatory for
management of these patients to see for ciliary injecOphthalmology Update Vol. 13. No. 2, April-June 2015
The Efficacy of Limbal Based ConjunctivalFlap in Patients Undergoing Trabeculectomy with Intra-operative Mitomycin tion and corneal oedema, optic disc cupping, intraocular pressure, angle details and visual field defects.
Glaucoma is a highly prevalent and vision threatening
condition affecting approximately 66 million people
worldwide.2 In a recent study conducted in Pakistan,
it was showed that glaucoma accounted for 8.1% of all
eye admissions. Open-angle glaucoma was responsible
for 37.6% or 731 glaucoma admissions followed by secondary glaucoma (35.0%) and angle-closure glaucoma
(18.2%).3
In our set-up, people present with advance disease
due to poverty, illiteracy and lack of district-based eye
care. Different types of treatment options are available
like anti-glaucoma drugs, laser treatment and surgical interventions. Treatment of choice in our setting is
surgical intervention due to poverty, poor drug compliance, late presentation and high failure rate of laser
trabeculoplasty.4 Trabeculectomy alone introduced by
Cainrs in 1968 and modified by Watson in 1970,5, 6 or
with antimetabolite (Mitomycin-C, 5-Fluoro-urocil) has
been the surgical method of choice.7 ,8 9
Objective; To determine the efficacy of Limbus based
conjunctival flap in patients undergoing trabeculectomy with intraoperative Mitomycin C.
Efficacy: it will be measured on the basis of conjunctival bleb formation and normal intraocular pressure (1121mmHg) and thus affectivity of the procedure will be
assessed.
MATERIAL AND METHODS
Setting: Department of Ophthalmology, Khyber Institute of Ophthalmic Medical Sciences (KIOMS), Post
Graduate Medical Institute, Lady Reading Hospital,
Peshawar.
Duration of Study: 18 months, from 1st January2012 to
30th June 2013.
Sample Size: Using WHO sample size calculator, where
Confidence level=95,
Absolute precision=0.03,
Population proportion (P) =10%.
The sample size=80
Sampling Technique: non probability: consecutive
SAMPLING SELECTION
a. Inclusion criteria;
i. patients of 30 to 60 years, both male and female.
ii. Patients of primary open angle glaucoma,angle
closure glaucoma pseudoexfoliative glaucoma
and induced glaucoma with raised intra ocular
pressure not controlled by maximum treatment or
poor compliance.
b. Exclusion criteria;
Patients with previously failed trabeculectomy.
Patients with history of previous intra ocular surOphthalmology Update Vol. 13. No. 2, April-June 2015
gery or trauma.Patients with congenital or normal
tension glaucoma. Patients with secondary glaucoma like uveitic, neovascular or pseudophakic
Study design: prospective, interventional case series.
Data collection procedure: The study was conducted
at Out Patient Department, Eye Unit of Lady Reading
Hospital, Peshawar. Before we start the study, permission from the hospital ethical committee was obtained.
An informed written consent was obtained from the
patient. The patients were evaluated for inclusion and
exclusion criteria. Patients for trabeculectomy will be
admitted to eye unit of Lady Reading Hospital, Peshawar, through an eye OPD waiting list. A detailed history regarding dimness of vision (DV) (whether sudden
or gradual, painless or painful), previous ocular trauma
and intraocular surgery will be taken. Pre-op ocular examination including best corrected visual acuity, relative afferent papillary defect( RAPD) and slit lamp examination of optic disc with 90 D lens noting optic disc
cupping and cup-disc ratio( c/d ratio), gonioscopic examination of angle structure by Goldmann single mirror goniolens, intraocular pressure measurement(IOP)
by Goldmann applanation tonometer and visual field
testing using Humphery perimeter. Laboratory investigations like Hb %, HBA1C, Ag, anti-HCV, blood sugar
etc will be done in Pathology Department, Lady Reading Hospital, Peshawar. Radiological investigations
like chest X-Ray will be done in Radiology Department,
Lady Reading Hospital, Peshawar. The surgery will
be done both under local and general anesthesia. On
first day after surgery and on follow up the patients
will be assessed for visual acuity, conjunctival bleb,
and intraocular pressure. Patients will be examined on
first post-op day and will be discharged after being followed up on 10th postoperative day and 1 month. Nominal data of the outcome of surgery for all the patients
will be recorded on a data collection proforma on each
follow up visit.
Surgical Procedure: Limbal based trabeculectomy was
performed.
Data analysis procedure: After completion of data collection, the data will be analyzed using SPSS version
13.0. All categorical variables including gender and
operative outcome will be given in frequencies and
percentages; mean and standard deviation will be calculated for numerical variables for example age and
intraocular pressure on day 1, 10, and 30. Operative
outcome in the form of intraocular pressure and bleb
formation was documented and presented in the form
of tables.
RESULTS
Eighty patients were diagnosed as “Glaucoma”
101
The Efficacy of Limbal Based ConjunctivalFlap in Patients Undergoing Trabeculectomy with Intra-operative Mitomycin admitted at Ophthalmology Unit, KIOMS, Lady Reading Hospital, Peshawar. Eighty eyes of eighty patients
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
years as shown in table 1. In 80 eyes trabeculectomy
with limbal based conjunctival flap and intra-operative
Mitomycin C (MMC) was performed as primary procedure. At presentation the IOP was ranged from 24-32
mmHg, with mean of 27.28 mmHg with ± 2.32 standard deviation. Intraocular distribution is given in table
3. Among these 80 patients right eye was involved in
39 (48.8%) and left eye was involved in 41 (51.3%) as
shown in figure 2. After full assessment, patients had
postoperative follow up of one month. During this period intraocular pressure and bleb formation were assessed at 1st day, 10th day and 30th day postoperatively.
Postoperative intraocular pressure (IOP) was assessed.
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 formation was assessed postoperatively on day 1st, day 10th
and day 30th i.e. 85%, 100% and 100% as shown in table
7 and 8. In my study final mean IOP was12.12 ± 0.68.
Table-2: Pre-operative Intraocular pressure
with respect to procedures (n=80)
IOP
n
24-26 mmHg
19
27-29 mmHg
13
30-32 mmHg
8
IOP=Intraocular pressure
Table-3: IOP on 1st Post-Operative day
with respect to procedures (n=80)
N
Mean IOP
Std. Deviation
40
11.72
2.22
IOP= Intraocular pressure
Table-4: IOP on 10th Post-Operative day
with respect to procedures (n=80)
Procedure
N
Mean IOP
Std. deviation
Limbal based
40
12.12
0.68
Key.IOP= intraocular pressure
Table-5: IOP on 30th Post-Operative day
with respect to procedures (n=80)
Procedure
N
Mean IOP
Std. Deviation
40
12.12
0.68
Key:n= total number of eyes
IOP= Intraocular pressure
Table-6: Bleb formation on 1st postoperative
day with respect to procedures (n=80)
Procedure
Bleb formed Bleb Not formed
Total
Fornix based
40
0
40
Limbal based
34
06
40
Key: n= total number of eyes
Table-7: Frequency of bleb formation on 10th
post-operative day with respect to procedures (n=80)
Figure-1: Distribution of cases by Gender
Procedure
Bleb formed
Bleb Not formed
Total
Fornix based
40
00
40
Limbal based
40
00
40
Key: n= total number of eyes
Table-8: Bleb formation on 30th post-operative
day with respect to procedures (n=80)
Procedure
Bleb formed
Bleb Not formed
Total
Limbal based
40
00
40
Key. n= total number of eyes
Figure-2: Distribution with respect to Eye Involved (n=80)
Table-1: Age Distribution (n=80)
Age(years)
102
Minimum
Maximum
Mean
Std. Deviation
32
60
54.10
5.63
DISCUSSION
This study was conducted in Ophthalmology Department, Khyber Institute of ophthalmic Sciences/
Lady Reading Hospital, Peshawar. In this study eighty
eyes of glaucoma patients were included. The surgical
management of glaucoma has progressed and evolved
throughout the years. With advances in surgical technique, such as the use of adjunctive antifibrotic or antimetabolic agents and the placement of adjutable sutures, glaucoma surgery has become a more reliable
Ophthalmology Update Vol. 13. No. 2, April-June 2015
The Efficacy of Limbal Based ConjunctivalFlap in Patients Undergoing Trabeculectomy with Intra-operative Mitomycin and predictable undertaking.10 Trabeculectomy with
MMC augmentation is a safe and effective procedure
for reduction of IOP and visual rehabilitation whether a
fornix- or a limbal-based conjunctival flap is utilized.10
My study presents outcome data comparing the
limbal flap design in trabeculectomy procedures. In
this study 45 (56.3%) of patients were male and 55
(43.8%) were female. In a study by A Alwitry,10 28 were
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
female. In my study mean age is 54 years (32-60) +/5.63.In a study by A Alwitry,10 mean age was 69.74
years (23-85years). In a study by Tham CC1,3 mean age
was 48.1years +/- 21.9.In a study by Susan L Jee11, The
mean patient age was 65.4 years (range, 18–89 years).
Preoperative intraocular pressure (IOP) was measured
with mean IOP ± SD of 27.15 ± 2.60 mmHg. In a study
by A Alwitry,10 mean IOP in Limbal based group was
26.09mmHg+/-7.71. In a study by Zdravko Mandic,14
the mean IOP in Limbal based trab was 22.4 +/- 4.5
mmHg. While bleb was formed in 85%, 100% and 100%
of patients on 1st, 10th and 30th postoperative day respectively. In a study by Henderson,15 leaked was seen
in 10 out of 41 limbus based flaps (24%) on the 1st postoperative day. In a study by Wu L,16 bleb was functional
in 90.4%. In a study by F Grehn,17 6 out of 30 filtering
blebs (20%) of the Limbus-based trab. were judged as
avascular. In my study Postoperative IOP in Limbal
based group was 11.17 ± 2.2 on 1st postoperative day,
In a study by A Alwitry,10 mean IOP was 10.86 +/- 5.98.
In my study mean IOP on 10th postoperative day was
12.1 ± 0.68. In a study by A Alwitry,10 mean IOP was
8.85 +/- 4.35. In my study final mean IOP was12.12 ±
0.68, In a study by A Alwitry,10 mean IOP was 13.30 +/8.23. In a study by Zdravko Mandic1,4 mean IOP was
15.9 +/- 3.2 mmHg. In a study by Tezel G,18 the limbusbased conjunctival flap group, 146 eyes (97%) achieved
an IOP of less than 20 mm Hg.
CONCLUSION
• Glaucoma is a common vision threatening condition affecting both sexes.
• It is more likely occur in older individuals.
• Patients present with different types of signs and
symptoms depending upon the type of glaucoma.
The most common of which is decreased visual
acuity.
• In our setup patients usually presents with advance disease, so the treatment of choice is surgical intervention due to late presentation, poor
drugs compliance and poverty.
• Trabeculectomy with fornix based conjunctival
flap and MMC is more effective than trabeculectoOphthalmology Update Vol. 13. No. 2, April-June 2015
•
my with limbal based conjunctival flap and MMC,
as the chances of bleb non-formation due to leakage is more common on 1st postoperative day in
the latter procedure.
Surgical procedure is cost effective and reduces
the use of lifelong antiglaucoma drugs. Drugs side
effects can be avoided with surgical procedures.
Surgery should better be performed by an experienced surgeon.
REFERENCES
1.
Durrani J. Taking up the gunlet against the gruesome grave
glaucoma [Editorial]. Pak J Ophthalmol 2000;2:67-9.
2.
Thylefors B, Negral AD, Pararajasegaram R, Dadzie KY. Global
data on blindness. Bull World Health Org 1995;73:115-21.
3.
Qureshi MB, Khan MD, Shah MN, Ahmad K. Glaucoma admissions and surgery in public sector tertiary care hospitals in
Pakistan: results of a national study. Ophthalmic Epidemiol
2006;13:115-9.
4.
Babar TF, Saeed N, Masud Z, Khan MD. A two years audit of
glaucomas in admitted patients at Hayatabad medical complex
Peshawar. J Postgrad Med Inst 2004;18:284-92.
5.
S Fraser. Trabeculectomy and antimetabolites. Br J Ophthalmol. 2004;88:855– 6.
6.
Watson PG. Trabeculectomy, a modified ab externo technique.
Ann Ophthalmol 1970;2:199-205.
7.
O’Brart DP, Shiew M, Edmunds B. A randomised, prospective
study comparing trabeculectomy with viscocanalostomy with
adjunctive antimetabolite usage for the management of open
angle glaucoma uncontrolled by medical therapy. Br J Ophthalmol. 2004;88:1012-7.
8.
Palanca-Capistrano AM, Hall J, Cantor LB, Morgan L, Hoop J.
Long-term outcomes of intraoperative 5-fluorouracil versus intraoperative mitomycin C in primary trabeculectomy surgery.
Ophthalmology. 2009;116:185- 90.
9.
Wilkins M, Indar A, Wormald R. Intra-operative mitomycin C for glaucoma surgery. Cochrane Database Syst Rev.
2005;(19):CD002897.
10. A Alwitry, V Patel, AW King. Fornix vs limbal-based trabeculectomy with mitomycin C.Eye 2005; 19: 631–636.
11. Susan J Lee,Augusto Paranhos,M Bruce Shields.Does titration
of mitomycin C as an adjunct to trabeculectomy significantly
influence the intraocular pressure outcome? Clin Ophthalmol
2009;3:81- 7.
12. W L Membrey, D P Poinoosawmy, C Bunce, R A Hitchings.
Glaucoma surgery with or without adjunctive
antiproliferatives in normal tension glaucoma: 1Intraocular pressure control and complications. Br JOphthalmol 2000; 84: 586–90.
13. Tham CC, Lai JS, Poon AS,Lai TY, Lam DS .Resul trabeculectomy with adjunctive intraoperative mitomycin C in Chinese
patients with glaucoma. Ophthalmic Surg Lasers Imaging. 2006;37:33-41
14. Mandiæ Z , Benèiæ G , Geber M Z , Bojiæ L . Fornix vs Limbus
Based Flap in Phacotrabeculetomy with Mitomycin C: Prospective Study.Croatian Medical Journal 2004; 45:275-278.
15. Henderson H W A , Ezra E , Murdoch I E . Early postoperative
trabeculectomy leakage: incidence, time course, severity, and
impact on surgical outcome: Br J Ophthalmol 2004; 88:626-629.
16. Wu L,Yin J The effect of mitomycin C on filtration surgery
of glaucoma with poor prognosis. Zhonghua Yan Ke Za Zhi
1996;32:32-4.
17. Tezel G, Kolker AE, Kass MA, Wax MB. Comparative results
of combined procedures for glaucoma and cataract: II. Limbusbased versus fornix-based conjunctival flaps : Ophthalmic
Surg Lasers. 1997 ;28:55118. Grehn F, Mauthe S, Pfeiffer N . Limbus-based versus Fornixbased conjunctival flap in filtering surgery: International Ophthalmology 1989;13:139-143.
103
ORIGINAL ARTICLE
Akhunzada M. Aftab
Normal Tension Glaucoma &
Cerebral Ischemia / Brain Atrophy
Akhunzada Muhammad Aftab FCPS1, Awais Rauf MBBS2, Asif MBBS3
Prof. Mustafa Iqbal FRCS, FRCOphth4, Sobia Sabir Ali FCPS5, Atif Rana FCPS6
ABSTRACT
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 normaltension glaucoma.
INTRODUCTION
Glaucoma encompasses a heterogeneous group of
conditions, resulting in optic nerve damage and characteristic visual field changes. It is usually but not always
associated with raised intraocular pressure (IOP). Normal-tension glaucoma (NTG) is a chronic optic neuropathy with features similar to primary open-angle
glaucoma (POAG), with the exception of a consistently
normal IOP, i.e. less than 22 mm Hg.1 The disease usually presents in old age and has a female predilection.
The exact etiology of NTG is uncertain and various risk
factors have been postulated. These include:
• Generalized peripheral vascular endothelial dysfunction.2
• Ocular circulation insufficiency (lower ocular
pulse amplitude)2
• Increased resistance index in the central retinal artery (role in progression of visual field defect)3
Registrar Eye A Unit Department of Ophthalmology, Khyber Teaching
Hospital, Peshawar. 2,3Trainee Medical Officers. A Unit Department of
Ophthalmology, Khyber Teaching Hospital, Peshawar. 4Prof. & Head
of Ophthalmology, 5Head of Endocrinology Department. 6Consultant
Radiologist, Shifa International Hospital
1
Correspondence: Dr. Akhunzada Muhammad Aftab c/o Prof.
Dr. Muhammad Ibrar, Department of Botany, University of Peshawar,
Peshawar. Cell: 03339106060, E-Mail: draftab@live.com
Received: February 2015
Accepted: February 2015
Financial Disclosure: There has been no financial interest involved
in this study
104
•
Impaired vascular auto regulation (prolonged
arteriovenous venous passage time in relation to
ocular perfusion)4
• Migraine
• Peripheral vasospasm, Raynaud syndrome
• Autoimmune disorders
• Systemic vascular disease (i.e. atherosclerotic disease, cerebrovascular insufficiency)5,6
• Systemic nocturnal hypotension
• Sleep apnea (decreases oxygen saturation)7
Cerebral ischemia and (or) brain atrophy is a recognized risk factorand researchers are taking keen interest in this hypothesis. Optic nerve being a part of
the central nervous system is affected in the same way
as the brain. This theory is supported by some studies
which have found a significant portion of patients diagnosed as NTG to have cerebral ischemia and (or) brain
atrophy. In our department, we investigated patients
diagnosed as normal tension glaucoma for occurrence
of concurrent cerebral ischemia and (or) brain atrophy
using magnetic resonance imaging.
MATERIAL AND METHODS
Patients diagnosed with normal tension glaucoma
were included in the study. All patients 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
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 thromboplastin time (APTT), HbA1c and fasting lipid profile.
Other investigations included 8- hourly blood pressure
monitoring, ECG, echocardiography and carotid doppler 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. Concurrent conditions like diabetes, hyperlipdemia and hypertension were actively managed in consultation with
an endocrinologist and a cardiologist.
RESULTS
Our study included 19 patients. Male patients included in our study were 7 (37%) while there were 12
(63%) females. Mean age was 60 years (range 42- 75
years). None of the study patients recorded a corrected
IOP reading of more than 21 mmHgon phasing. Two
(10%) patients suffered from diabetes, 10 (53%) patients
had hypertension while 5 (26%) patients were diagnosed as both diabetic and hypertensive. One (5%) patient in our study group had raised triglyceride levels.
There were 2 (10%) patients with history of migraine.
None of the study patients was reported to have sleep
apnea.
Echocardiography revealed abnormalities in 6
(32%) patients. These included diastolic dysfunction in
3 patients. Mild mitral valve regurgitation was reported in 2 patients while one patient had mild aortic valve
regurgitation. Carotid Doppler scans did not reveal
significant stenosis (>75%) in any of the study patients.
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.
Figure-1: Associated risk factors in patients diagnosed with NTG
Ophthalmology Update Vol. 13. No. 2, April-June 2015
Figure-2: MRI Brain findings in our study.
DISCUSSION
The exact patho-physiology causing optic nerve
damage in normal tension glaucoma is still uncertain
and a matter of ongoing debate. Intra ocular pressure,
the only factor with other types of glaucoma has in
common is not related to this condition. Probably that
is the reason why anti glaucoma medications, which
lower the IOP have not been proven effective in halting the progression of the disease process. Stroman
GA et al. reported an increased incidence of cerebral
small vessel ischemia in patients with normal tension
glaucoma compared to control subjects and proposed
the theory of vascular damage of optic nerve in these
patients.6 Another study conducted at The Sydney Eye
Hospital, Australia compared MRI of brain of patients
with NTG with control subjects. They concluded that
patients with NTG had increased incidence of cerebral
infarcts, the thickness of the body and genu of corpus
callosum was thinner as compared to control subjects.
They also postulated an ischemic patho-physiologic basis for NTG.8
Optic nerve damage and progression of visual
fields loss also seems to be related to cerebral ischemia.
In NTG patients with cerebral ischemia on MRI, the
visual fields showed deeper depression in the inferior
pericentral visual field and has been marked as an independent 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 number (79%) of patients diagnosed as NTG had signs of
cerebral ischemia and (or) brain atrophy indicated on
magnetic resonance imaging of brain and visual pathway. This further acknowledges the hypothesis that ischemic 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
hence is subjected to similar insults.
105
Normal Tension Glaucoma & Cerebral Ischemia / Brain Atrophy
CONCLUSION
The study suggests a greater incidence of cerebral
ischemia and (or) brain atrophy in patients with normal-tension glaucoma. Optic nerve damage in such patients may be an extension of the same disease process.
REFERENCES
1.
Kim M, Kim TW, Park KH, Kim JM. Risk factors for primary
open-angle glaucoma in South Korea: the Namil study. Jpn J
Ophthalmol. 2012 Jul;56(4):324-9
2.
Su WW, Cheng ST, Hsu TS, Ho WJ. Abnormal flow-mediated
vasodilation in normal-tension glaucoma using a noninvasive
determination for peripheral endothelial dysfunction. Invest
Ophthalmol Vis Sci. 2006 Aug;47(8):3390-4
3.
Delaney Y, Walshe TE, O’Brien C. Vasospasm in glaucoma: clinical and laboratory aspects. Optom Vis Sci. 2006 Jul;83(7):406-14
4.
Plange N, Kaup M, Remky A, Arend KO. Prolonged retinal
arteriovenous passage time is correlated to ocular perfusion
pressure in normal tension glaucoma. Graefes Arch Clin Exp
Ophthalmol. 2008 Aug;246(8):1147-52
5.
Harris A, Siesky B, Zarfati D, et al. Relationship of cerebral
6.
7.
8.
9.
10.
blood flow and central visual function in primary open-angle
glaucoma. J Glaucoma. 2007 Jan;16(1):159-63
Stroman GA, Stewart WC, Golnik KC, Curé JK, Olinger RE.
Magnetic resonance imaging in patients with low-tension glaucoma. Arch Ophthalmol. 1995 Feb;113(2):168-72
Bilgin. Normal-tension glaucoma and obstructive sleep apnea syndrome: a prospective study. BMC Ophthalmol. 2014
March;(10):14-27
Ong K, Farinelli A, Billson F, Houang M, Stern M. Comparative
study of brain magnetic resonance imaging findings in patients
with low-tension glaucoma and control subjects. Ophthalmology. 1995 Nov;102(11):1632-8.
Suzuki J, Tomidokoro A, Araie M, Tomita G, Yamagami J,
Okubo T, Masumoto T. Visual field damage in normal-tension
glaucoma patients with or without ischemic changes in cerebral magnetic resonance imaging. Jpn J Ophthalmol. 2004 JulyAug; 48(4): 340-44
Leung DY, Tham CC, Li FC, Kwong YY, Chi SC, Lam DS. Silent cerebral infarct and visual field progression in newly diagnosed normal-tension glaucoma: a cohort study. Ophthalmology. 2009 Jul;116(7):1250-6.
Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disease (phacomatosis) with variable clinical manifestations
(see the main article) Curtesy: Dr Hussain Ahmad Khaqan Department
of Ophthalmology, Lahore General Hospital/PGMI, Lahore.
106
Ophthalmology Update Vol. 13. No. 2, April-June 2015
Complications & Results of
External Dacryocystorhinostomy in Chronic
Dacryocystitis without Intubation
ORIGINAL ARTICLE
(Review of 107 Cases.)
Mohammad Alam
Mohammad Alam FCPS1, Misbah Durrani FCPS2, Prof. Lal Mohammad FCPS3
Arshad Farooq FCPS4
ABSTRACT:
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 syringing 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)
INTRODUCTION
NLD blockade results in watering of disturbed
tears called Epiphora which is the most bothersome
problem of lacrimal system obstruction. Management
of Epiphora has evolutionary history. Adeo Toti was
the first who introduced dacryocystorhinostomy for
the treatment of epiphora.1 He created an external approach to lacrimal sac by creating a window in nasal
lateral wall. The results of Adeo Toti were not successful in many patients. This procedure was modified by
Bourguet and Dupuy-Dutemps. They introduced anastomosis of mucosa with suturing of the mucosal flaps.2
Ohm added suturing of anterior and posterior flaps of
nasal mucosa with lacrimal sac.3 External DCR is the
mostly practiced operation for NLD obstruction. Usually other methods of surgery for CDC are compared
Assistant Professor Ophthalmology KMU Institute Of Medical
Sciences, K.D.A Kohat. 2Assistant Professor, Radiology, Bacha Khan
Medical College, Mardan. 3Professor of Ophthalmology KMU Institute
of Medical Sciences, K.D.A Kohat. 4Assistant Professor ENT KMUInstitute of Medical Sciences, KDA Kohat
1.
Correspondence: Dr. Mohammad Alam1 Assistant Professor
Ophthalmology KMU Institute of Medical Sciences K.D.A Kohat.
malamktk@gmail.com, Cell:
Received: December 2014
Accepted: February 2015
Ophthalmology Update Vol. 13. No. 2, April-June 2015
with this gold standard procedure.4 Various studies
have reported external DCR success rate more than
80% which depends upon the surgeon experience.
There are other methods of surgical procedure to
treat NLD obstruction. These include endoscopic DCR,
endoscopic laser nasal DCR, endoscopic radio frequency assisted DCR.5,6,7 Endoscopic DCR is the favored surgical procedure of ENT surgeon and thus ophthalmologists and ENT surgeons share their clinical skill and
experience in care and treatment of NLD obstruction
patients.8 There are numerous modifications in various
surgical steps that has been introduced in DCR over
years to get better results. Various national and international studies have reported low complications rate
in external DCR. We present our experience in external
DCR with only anterior flaps suturing.
MATERIALS AND METHODS
This prospective study was conducted in Eye
Care Centre Karak and KDA Teaching Hospital Kohat
from March, 2008 to March, 2014 with the objective to
know the success rate and complications of external
DCR without silicone tube intubation. Total 107 patients with age range of 31 to 63 years with mean age of
44.7 years were selected table I. Out of 107 patients 63
(58.87%) were male and 44 (41.12%) were female (Ta107
Complications & Results of External Dacryocystorhinostomy in Chronic Dacryocystitis without Intubation
ble II). Indications for DCR were epiphora and chronic
dacryocystitis. Diagnosis of all patients was made by
regurgitation test and syringing of NLD system.
Inclusive criteria:
• CDC patients with Regurgitation test positive and
NLD blocked by syringing.
Exclusive Criteria:
• Hypertensive Patients Canalicular obstruction
• Nasal trauma patients
• Previously operated DCR
All the patients were operated under local anesthesia. Nasal packing in all the patients was done with
gauze soaked in 4% Xylocaine and 1 in 100000 adrenaline. Lacrimal sac area was infiltrated with 2% xylocaine
with 1 in 100000 adrenaline. DCR was done with Bourguet and Dupey-Dutemps Technique. Anterior and posterior 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 applied. After skin stitches homeostasis was secured. Nasal pack was removed and syringing of the NLD system was done on the table. Haemostasis was secured on
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. Syringing was done with follow up on 10 day one month, 3rd
month and 6th month. Successful results were considered
to be negative regurgitation test and on syringing patent NLD along with patients satisfaction.
RESULTS
During surgery bleeding from nasal mucosa was
observed in 11 (10.28%) patients nasal bone bleeding from 9 (8.41%) patients, tear in nasal septum in
2(1.86%)patients. Regarding immediate/early postoperative complications bleeding in 4 (3.73%) periorbital swelling/ecchymosis in 13 (12.14%) patients while
wound infection with cellulitis was observed in 9 (8.4%)
patients.(table IV).
Regarding results of success, over all 95 (88.78%)
DCR were successful, while in 7 (6.5%) patients epiphora was present on subsequent follow up and epiphora with discharge was present in 5 (4.67%) patients
(Table V). In these 12 patients on syringing NLD was
observed blocked.
Table-I: Age distribution
108
Age in Years
No of Patients
%age
31 – 40
19
17.75
41 – 50
67
62.61
51 – 60
14
13.08
61 – 63
07
6.54
Table-II: Gender Distribution
Gender
Number of patients
%age
Male
63
58.87
Female
44
41.12
Table-III: Complications during surgery
Complications
Number of patients
percentage
Nasal mucosal bleeding
11
10.28%
Nasal bone bleeding
09
8.41%
Tear in nasal septum
02
1.86%
Table-IV: Immediate postoperative complications
Number
of patients
percentage
Wound infection with cellulitis
9
8.41%
Postoperative Bleeding
4
3.73%
Periorbital ecchymosis/swelling
13
12.14%
Complications
Table-V: Results
No of Patients
%age
Epiphora
Results
07
6.54%
Epiphora with discharge
05
4.67%
Successful DCR
95
88.78%
Total
107
100
DISCUSSION
In our study results had success rate of 88.78%
and complications were found being managed early.
Moreover in our patients male were more than female.
Our study has some similarities to National and International studies. But also variations were found in various aspects of the patients after complete follow up.
Emed S M H has reported success rate of 88.7%
of external DCR without intubation which is similar
to our study, but in his study female were more than
male.9 Complications reported are also negligible in his
study. Rehman A, Channa S have reported 97.77% success rate of external DCR without intubation but they
had used mitomycin C during surgery.10 Probably this
may be due to mitomycin C. ­­­­­­­­ Besharati MR, Rastigor A
have reported in their study of External DCR success
rate of 88% and failure rate of 9.6%, wound infection
in 5.3% and granuloma formation in 3.2% patients. The
results are comparable to our study.11 Darade DM. Sahasrabudhe VM, Khaire BS et al have reported in external 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 canalicular 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 reveals 100% anatomic patency results in external DCR.
However, epiphora was present in 6.7% patients despite of anatomic patency of NLD.13 Muhammad Al
Droos study on external DCR reveals female to be more
than male and the complications reported are more than
our study like transient lagophthalmos, wound dehiscence and Transient orbicularis hypotony.14 Tsirbas A,
Mc Nab had demonstrated secondry haemorhage in
external DCR in 10 patients out of 293 DCR, which has
not been found in our study. They have also shown a
failure rate of 8.5%.15 Now-a-days endoscopic DCR is
also in practice but the results of success rate is not as
in external DCR. Whitaker JKH, Hall AB, Dhalla KH
have reported success rate in discharge and epiphora
resolution to be 90.9% and 84.4% patients with external
DCR.16 Mekonnen W, Adanbu Y have shown 93% success rate of external DCR.17 Zaman M, Babar TF, Saeed
N have reported over all success rate of 98.33% in external DCR. The success rate of this study is high than
our study. However the complications mentioned in
the study are comparable to our study.18
CONCLUSION
External DCR is the most popular and fruitful surgical procedure with high success rate and less complications. This procedure has short learning curve. It
can be performed on local anesthesia and in most cases
intubation is not necessary.
REFERENCES
1.
Toti A. Nuovo metodo conseravative di cura radicalle delle
supporazioni chronicle del sacco lacrimale Clin Mod Firenze
1904;10: 385-9.
2.
Dupuy-Dutemps L, Bourguet J. Procede plastique de dacryocystorhinostomie et ses resultants. Ann Ocul J 1921; 158: 241-61.
3.
Ohm J. Nerbesserungen an meinen Nystagmographen. Klin
Monatsble Augenheilk 1926; 1:791-4.
4.
Seppa H, Grenman R, Hartikainen J. Endonasal Co2-Nd: YAG
laser dacryocystorhinostomy. Acta-ophthalmol Copenh. 1994;
Ophthalmology Update Vol. 13. No. 2, April-June 2015
5.
6.
7.
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9.
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72 (6): 703-6.
Yazici Z Yazici B, Paarlak M, Ertirk H, Savi G. Treatment of
obstructive epiphora in adult by balloon dacryocystoplasty. Br
J Ophthalmol 1999; 83 (6): 692-6.
Moore WM, Bentley Cr, Olver JM. Functional & anatomic results after two types of endoscopic endonasal dacryocystorhinostomy: surgical and holmium laser. Ophthalmology 2002;
109 (8): 1575-82.
Unlu HH, Toprak B, Aslan A, Guler C. Comparison of surgical
outcomes in primary endoscopic dacryocystorhinostomy with
and without intubation. Ann Otol Rhinol Laryngol 2002; 111
(8); 704-9.
Al.shaikh S,Javed F,et al.UK Survey of the present role of ear,
nose and throat surgeons in lacrimal surgery.Ann R Coll Surg
Engl.Oct 2010;92(7):583-586.
Emad SMH.Comparison of results and complications of external dacryocystorhinostomy with and without silicone tube.
JBUMS 2008 ,10(5):62-67.
Rehman A,Channa S,Niazi JH et al.Dacryocystorhinostomy
without intubation with inraoperative mitomycin-C. journal of the college of Physician and Surgeon Pakistan: JCPSP
.2006;16(7):476-8.
Besharati MR,Rastegar A. Results and complications of external dacryocystorhinostomy surgery at a teaching hospital in
Iran.Saudi Med J.2005.Dec;26(12):1940-4.
Darade DM,Khaire BS,et al. Outcome of Modified Anterior
Flaps Anastomosis Technique of External Dacryocystorhinostomy.Medical Science Vol 4 issue 11.Nov 2014.
Choung HK,Khwarg SI.Selective non-intubation of a silicone
tube in external dacryocystorhinostomy. Acta Ophthalmol.
Scand.2007;85:329-332.
Aldroos M.Postoperative external dacryocystorhinostomy
complications. Int J Biol Med Res. 2013; 4(2): 3066 – 3069.
Tsirbas A.and McNab,A.A(2000),Secondary haemorrhage after
DCR. Clinical & experimentalOphthalmology. Volume 28, Issue 1,(/doi/10.1111/ceo.2000.28.issue-/issuetoc)pages 22 – 25,
February 2000.
Whitaker JKH, Hall AB Dhalla KH. Outcomes and reasons for
DCR at KCMC,aTanzanian referral Hospital,2001-2006.African
Health Sciences,Vol.11,NO.2,April-June,2011,-252-254.
Mekonnen W, Adamu Y. Outcome of external dacryocystorhinostomy in Ethopian patients Ethiop Med J 2009; 47:221-6.
Zaman M,Babar TF ,Saeed N. A review of 120 cases of dacryocystorhinostomies (Dupuy Dutemps and Bourguet Technique.J
Ayub Med Coll Abbottabad.2003 Oct-Dec;15(4):10-2.
109
ORIGINAL ARTICLE
Recurrence of Retinal Detachment
after Silicone Oil Removal
Bilal Khan
Bilal Khan FCPS1, Mumtaz Alam FCPS2, Bilal Bashir FCPS3, Adnan Alam MBBS4
Mir Ali Shah FCPS5, Mehfooz Husssain FRCS6
ABSTRACT:
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 Ophthalmology, 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 under 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.
INTRODUCTION
The retina is an extremely thinnest tissue of the
eye. Most retinal detachments are a result of a retinal
break, hole, or a tear. Retinal breaks, holes, or tears are
not the result of trauma, but are due to pre-existing factors such as high levels of myopia and prior ocular surgery. Early diagnosis and repair of retinal detachments
is urgent since visual improvement is much greater
when the retina is repaired before the macula or central
area is detached.
Silicone compounds are unique materials both in
terms of the chemistry and in their wide range of useful
applications. Silicone in combination with organic compounds provides unique properties that function over
a wide temperature range, making the silicone based
products less temperature sensitive than most organic
surfactants.1
The use of silicone oil in retinal re-attachment
surgery was introduced by Paul Cibis2 in early 1960s,
1,3
Vitreo-Retina Trainee, Lady Reading Hospital Peshawar. 2Assistant
Professor, Ophthalmology Department Peshawar Medical College
Peshawar. 4Trainee Medical Officer, Lady Reading Hospital Peshawar. 5Associate Prof. Lady Reading Hospital Peshawar. 6Assistant
Prof. Lady Reading Hospital Peshawar
Correspondence: Dr. Bilal Khan Department of Ophthalmology, Lady
Reading Hospital Peshawar. Mob No: 0300-5981806
E-mail: drbilalokz@gmail.com
Reeived: January 2015
Accepted: February 2015
Sponsoring organization: None
110
based on the experimental work of silicone.3 Silicone
oil is used in vitreoretinal surgery to provide long-term
internal tamponade in cases of rhegmatogenous retinal detachment complicated by severe proliferative vitreoretinopathy (PVR) and giant retinal tears,4,5 severe
proliferative diabetic retinopathy (PDR), chronic uveitis with profound hypotony, selected cases of macular
hole, infectious retinitis, and vitreous hemorrhage after
penetrating ocular trauma.
Silicone oil is generally removed after 6 months if
the retina is attached and must be removed upon the
development of oil emulsification, keratopathy, secondary glaucoma or cataract.6 Compared with sulphur
hexafluoride gas (SF6) as an intraocular tamponade for
the management of retinal detachment, eyes treated
with silicone oil are more likely to be successfully reattached, to achieve a better visual acuity, and to have
fewer postoperative complications, particularly cataract, glaucoma, and keratopathy.7 The purpose of our
study was to find out the recurrence rate of retinal detachment after silicone oil removal.
MATERIAL AND METHODS
This was a retrospective review of 100 patients.
The study was conducted in the Department of Ophthalmology, Lady Reading Hospital Peshawar. All patients who underwent removal of silicone oil from the
eye between June 2012 to January 2014 were included
in the study. All patients included in the study had previously 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
endo-tamponade was carried out with endo-drainage
of sub-retinal fluid, use of perfluorocarbon liquids, endolaser coagulation, cryopexy and relaxing retinotomies. In all patients, silicone oil with a viscosity of 1000
centistokes was used. Before removal of the silicone oil,
the retina was attached in all patients. Silicone oil was
removed via pars plana sclerotomies in 100 patients
under peribulbar anaesthesia. 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 fe-
male (35%). Figure I shows the gender distribution of
patients. Age of the patients was ranging from 16 to 70
years, with a mean of 37 years. Table I shows the age
distribution of patients. 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 de-
Figure-I: Gender distribution of patients
Table-I: Age distribution of patients
Age
Number of patients
Percent
< 31 years
25
25 %
31-40 years
39
39 %
41-50 years
18
18 %
51-60 years
11
11 %
61-70 years
07
07 %
Table-II: Recurrence of retinal detachment after
silicone oil removal in various studies
Authors
Pavlovic S et al
Scholda et al
19
Percentage
12.0%
17
20.5%
Scholda et al13
16.1%
Falkner et al
Journal & Year
Ophthalmology 1995
Acta Ophthalmol Scand
1997
Acta Ophthalmol Scand
2000
17.4%
Br J Ophthalmol 2001
16
25.3%
Br J Ophthalmol 2001
Darakhshanda K et al15
38.0%
Pak J Ophthalmol 2011
Zafar S et al
20.0%
JCPSP 2013
Khan B et al (Our study)
25.0%
Not published yet
Jonas et al
14
18
Ophthalmology Update Vol. 13. No. 2, April-June 2015
tached after removal of silicone oil. Of these 25 eyes, 17
eyes had proliferative vitreo-retinopathy (PVR), 7 eyes
had proliferative diabetic retinopathy and 1 eye had
uncomplicated rhegmatogenous retinal detachment.
Incomplete removal of the vitreous base, defined as
ophthalmoscopically visible remnants of the vitreous
base before removal of silicone oil, was significantly
higher in patients with retinal re-detachment than in
patients without postoperative retinal detachment.
DISCUSSION
Since the invention of the vitrectomy instrument,
the role of silicone oil as a vitreous substitute and retinal tamponade has expanded. The beneficial effects of
silicon oil have been confirmed in a multicenter clinical
trial by the silicon oil study group. More recently, the
beneficial effects of silicone oil have been re-confirmed
in a multicenter clinical trial by the silicone oil study
group.8,9
We did a retrospective review of 100 patients who
underwent removal of silicone oil from the eye, in the
Department of Ophthalmology Lady Reading Hospital
Peshawar, between June 2012 and January 2014 and
had completed 6 months follow up. The retina was attached and stable in all cases before silicon oil removal.
6 months after the removal of silicone oil, retina remained attached in 75 of the 100 (75%) patients included 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 silicone oil removal before emulsification.10,11,12
The cause of this re-detachment following silicone
oil removal was mostly residual traction and redevelopment of proliferative vitreo-retinopathy that had led
to reopening of pre-existing retinal breaks, or formation
of new retinal breaks as a result of surgical manipulations.
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
after silicone oil removal, and the underlying diseases.
Anatomical success after silicone oil removal, defined as complete retinal attachment was achieved in
75 (75%) out of 100 eyes in this study, whereas, retinal
re-detachment after silicone oil removal was seen in the
remaining 25%. Falkner et al reported 17.4% cases of
re-detachment after silicone oil removal in their study.14
Darakhshanda et al reported 38% re-detachment rate
after silicone oil removal.15 In another study, the reported rate of re-detachment after silicone oil removal was
25.3%.16 Scholda et al reported 20.5% cases of retinal detachment in their study.17 In another study, conducted
111
Recurrence of Retinal Detachment after Silicone Oil Removal
by Zafar S et al, the rate of re-detachment after silicone
oil removal was 20%.18 Pavlovic et al commented that
eyes with completely attached retinas, the risk of complication and re-detachment after silicone oil removal is
relatively low.19
This was a retrospective study and the different
risk factors for re-detachment after removal of silicone
oil were not studied in detail due to lack of data. Further prospective studies with larger sample size and
longer follow up needs to be done to identify the risk
factors for re-detachment.
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.
REFERENCES
1.
1O’Lenick AJ. Basic silicone chemistry: a review [Internet].1999.
Available from: http://www.siliconespectator.com/articles/
Silicone_Spectator_January_2009.
2.
Cibis PA, Becker B, Okun E, Canaan S. The use of liquid silicone
in retinal detachment surgery. Arch Opthalmol 1962; 68:590-9. 3.
Stone W Jr. Alloplasty in surgery of the eye. N Engl J Med 1958;
258:486-90.
4.
McCuen BW, Landers MB, Machemer R. The use of silicon oil
following failed vitrectomy for retinal detachment with advanced proliferative vitreoretinopathy. Graefes Arch Clin Exp
Ophthalmol 1986; 224(1);38-9.
5.
Cians JD, Campbell WG. Vitrectomy techniques in the treatment of giant retinal tear: a flexible approach. Clin Exp Ophthalmol 1988; 16:209-14.
6.
Nagpal M, Videkar R, Mehrotra N. Hybrid technique for silicone oil removal. Retina Today 2011; 36-40.
112
7.
8.
9.
10.
11.
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14.
15.
16.
17.
18.
19.
Lucke K, Strobel B, Foerster M, Laqua H. Secondary glaucoma after silicone oil surgery. Klin Monbl Augenheilkd 1990;
196:205-9.
Parrel JM. Silicone oil: physiochemical properties. In: Retina. Volume 3. Edited by Glaser BM, Michels RG. St. Louis: CV
Mosby. 1989;261-77.
Silicone study group. Vitrectomy with silicone oil or sulfur
hexafluoride gas in eyes with severe proliferative vitreoretinopathy: Results of a randomized clinical trial- Silicone Study
Report No 1. Arch Ophthalmol 1992; 110:770-9.
Kampik A, Hoing C, Heidenkummer HP. Problems and timing
in the removal of silicone oil. Retina 1992; 12(3):S11-6. Azen SP, Scott IU, Flynn HW Jr, Lai MY, Topping TM, Benati L,
et al. Silicone oil in the repair of complex retinal detachments.
A prospective observational multicentre study. Ophthalmology 1998; 105(9):1587-97.
Lewis H, Burke JM, Abrams GN, Aaberg TM. Perisilicone proliferation after vitrectomy for proliferative vitreoretinopathy.
Ophthalmology 1988; 95:5583-91. Scholda C, Egger S, Lakits A, Walch K, von Eckardstein E,
Biowski R. Retinal detachment after silicone oil removal. Acta
Ophthalmol Scand 2000; 78:182-6.
Falkner CI, Binder S, Kruger A. Outcome after silicone oil removal. Br J Ophthalmol 2001; 85:1324-7.
Darakhshanda K, Ghayoor I. Outcome of silicone oil removal
in eyes undergoing 3-port pars plana vitrectomy. Pak J Ophthalmol 2011; 27:17-20.
Jonas JB, Knorr HL, Rank RM, Budde WM. Retinal redetachment after removal of intraocular silicone oil tamponade. Br J
Ophthalmol 2001; 85:1203-7.
Scholda C, Egger S, Lakits A, Haddad R. Silicone oil removal:
results, risks and complications. Acta Ophthalmol Scand 1997;
75:695-9.
Zafar S, Bokhari SA, Kamil Z, Shakir M, Rizvi SF and Memon
GM. Outcomes of Silicone Oil Removal. JCPSP 2013; 23(7):4769.
Pavlovic S, Dick B, Schmidt KG, Tomic Z, Latinovic S. Long
term outcome after silicone oil removal. Ophthalmology 1995;
92:672-6.
Ophthalmology Update Vol. 13. No. 2, April-June 2015
CASE REPORT
Choroidal Melanoma in a Young Patient
Hussain Ahmad
Hussain Ahmad Khaqan FCPS, FRCS, FCPS (Vitreo Retina)1
Farrukh Jameel MBBS2, Hadia Jabeen MBBS3
Muhammad MBBS4, Usman Imtiaz MBBS5
ABSTRACT:
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.
INTRODUCTION
Choroidal melanoma is the most common primary
malignant intraocular tumor in adults and the second
most common type of primary malignant melanoma
in the body(1). Primary choroidal melanoma arises from
melanocytes within the choroid. Most choroidal melanomas are believed to develop from pre-existing melanocytic nevi, though de novo growth of choroidal melanomas also occurs.
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. 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 vessels, 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. BScan showed a multilobular mass arising form the choroid with typical acoustic hollowness at the base and
choroidal excavation (Fig-4). B-Scan also confirmed the
inferior exudative retinal detachment. MRI was done
to detect any extraocular extension. T1 weighted MRI
scan revealed hyperintense mass arising from choroid
and involving the optic disc. There was no extraocular
extension (Fig-5). Abdominal ultrasound didn’t detect
any metastasis and Chest X-Ray, CBC, LFT’s and RFT’s
were normal too. Enucleation was done and the specimen was sent for histopathology.
Fig-1
Senior Registrar Ophthalmology, Lahore General Hospital / PGMI,
Lahore. 2,3,4Residents in Ophthalmology, Lahore General Hospital /
PGMI, Lahore. 5Resident Ophthalmology at Alshifa Trust Eye Hospital, Rawalpindi
1
Correspondence: Dr. Hussain Ahmad Khaqan, Department of Ophthalmology Lahore General Hospital / PGMI, Lahore.
E-Mail: drkhaqan@hotmail.com, Postal Address: House No.87, Eden
Canal Villas, Canal Bank Road, Thokar Niaz Baig, Lahore.
Tel:+92-42-37498314,Cell:+92-300-4270233, Fax:+92-42-7223039
Received: December 2014
Accepted: January 2015
Ophthalmology Update Vol. 13. No. 2, April-June 2015
Fig-2
113
Choroidal Melanoma in a Young Patient
Fig-3
Fig-4
Fig-5
DISCUSSION
Posterior uveal melanoma is an uncommon disease with an incidence of 5–6 cases per 1 million population per year.2 It is usually diagnosed in the sixth
decade of life, and its incidence rises steeply with age.2
Uveal melanoma is rare in children.3 In most series, the
median age at diagnosis is 55 years.4 In Jensen’s series,4
rates of disease decreased in males after age 69 years. It
is the most common primary intraocular malignancy,
and the leading primary intraocular disease, which
can be fatal in adults.2 Choroidal melanomas may have
114
variable coloration, ranging from darkly pigmented to
purely amelanotic. They typically are dome-shaped.
As they enlarge, if they break through the Bruch membrane, they can assume a mushroom configuration.
Other shapes found for these tumors are bilobular,
multilobular, and diffuse. The last of these is characterized by lateral growth throughout the choroid with
minimal elevation; it occurs in about 5% of cases.
Treatment of primary choroidal melanoma without evidence of metastasis involves either globeconserving therapy or enucleation. In a randomized
clinical trial of patients with primary choroidal melanoma treated with globe-conserving iodine-125 brachytherapy 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 metastasis 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 lesion.11
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.
REFERENCE
1.
Jack J Kanski BB. Clinical Ophthalmology: A systematic Approach. 7th ed. Windsor: Elsevier; 2011.
2.
Myron Yanoff JSD. Ophthalmology. 4th ed.: Elsevier; 2014.
3.
Shields CL SJMJea. Uveal melanomas in teenagers and children: a report 40 cases. Ophthalmology. 1991;(98): p. 1662-6.
4.
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.
5.
Diener-West M EJFSea. The COMS randomized trial of iodine
125 brachytherapy for choroidal melanoma. III. Initial mortality findings. COMS report no. 18. Arch Ophthalmol. 2001;(119):
p. 969-82.
6. Collaborative Ocular Melanoma Study Group. Ten-year follow-up of fellow eyes of patients enrolled in Collaborative
Ocular Melanoma Study random- ized trials: COMS report no.
22. Ophthalmology. 2004;(111): p. 966-76.
7.
The COMS randomized trial of iodine 125 brachytherapy for
choroidal mela- noma. V. Twelve-year mortality rates and
prognostic factors. COMS report no. 28. Arch Ophthalmol.
2006;(123): p. 1684-93.
8. Gragoudas ES EKSJea. Survival of patients with metastases
from uveal melanoma. Ophthalmology. 1991;(98): p. 383-90.
9.
Eskelin S PS, P S, al e. Tumor doubling times in metastatic malignant melanoma of the uvea: tumor progression before and
after treatment. Ophthalmology. 2000;(107): p. 1433-9.
10. Kath R HJBNae. Prognosis and treatment of disseminated
uveal melanoma. Cancer. 1993;(72): p. 2219-23.
11. Rajpal S MRKC. Survival in metastatic ocular melanoma. Cancer. 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
GENERAL
SECTION
ORIGINAL ARTICLE
Imran Yahaya
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
ABSTRACT
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-esophageal 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.
INTRODUCTION
Upper gastrointestinal bleeding (UGIB) is defined
as bleeding derived from a source proximal to the ligament of Treitz and Bleeding from the upper GI tract is
approximately 4 times as common as bleeding from the
lower GI tract.1 Acute gastrointestinal hemorrhage is a
common medical emergency. The mortality of patients
admitted to hospital for acute gastrointestinal bleeding
is about 10%, rising to more than 30% in patients who
bleed as inpatients.2 The incidence rates of UGIB demonstrate a large geo­graphic variation ranging from 48
to 160 cases per 100,000 population, with consistent reports of higher incidences among men and elderly people.3,4 Patients with acute upper gastrointestinal (GI)
bleeding commonly present with hematemesis and/or
melena.5 The mortality has decreased only minimally
Medical Officers Gastro Unit 3Senior Registrar, Gastroenterology
Unit, Hayatabad Medical Complex, Peshawar.
1,2,3,4
Correspondence: Dr. Waheed Ullah, FCPS., Medical Officer Gastro
Unit, Hayatabad Medical Complex, Peshawar. District Specialist,
DHQ Hospital,Village & P.O. Samarbagh, District lower Dir, KPK.
Cell: 0307 5040633 E-Mail: drwaheed2014@gmail.com
Received: Jan’2015
Accepted: Feb’2015
Ophthalmology Update Vol. 13. No. 2, April-June 2015
during the last 30 years, despite the introduction of endoscopic therapy that reduces the rate of rebleeding.1
Causes of non variceal upper GI bleeding include
peptic ulcer, Mallory-weiss tear, erosive gastritis/duodenitis, esophagitis/esophageal ulcer, malignancy,
angio-dysplasia/ vascular malformations and other
causes having incidence of 20-50%, 15-20%, 10-15%,
5-10%, 1-2%, 5% and 5% respectively.6,7 Currently,
OGD is the standard investigation of choice for UGIB.
Endoscopic therapy has revolutionized the treatment
of UGIB, with a recently greatly expanded therapeutic
armamentarium.8 In the place where urgent esophagogastro-duodenoscopy (EGD) is unavailable, empirical
pharmacological therapy with proton pump inhibitors
for non-variceal bleeding is recommended.9 Endoscopy
within 24 hours is recommended for most patients with
acute UGI bleeding.10, 11
The Blatchford score use only clinical and laboratory data (before endoscopy) to identify patients who
require intervention and predict future mortality. The
Blatchford score includes hemoglobin level, blood urea
level, pulse, systolic blood pressure, the presence of
syncope or melena, urea, syncope and evidence of he115
Frequency of High Glasgow Blatchford Score & its One Month Mortality in Patients presenting
patic disease or cardiac failure and accurately identifies
patients at low risk for clinical intervention like early
endoscopy by using the Blatchford score.12,13,14,15 In one
study, the frequency of High GBS was found to be 7884%2,16 and its 28 day mortality was reported to be up to
10%.2,16
This study is carried out to determine frequency
of high Glasgow Blatchford scoring system and its
one month mortality in patients presenting with nonvariceal UGIB so that we can categorize the patients in
high risk and low risk. GBS scoring system has been
traditionally used for UGIB bleed in terms of need of
blood transfusion, intervention and mortality; it has
very good value in categorizing the patients into low
risk and high risk.
The results of this study will be compared with
already available international data as the literature
suggested variable frequency of mortality of patients
having high GBS scores, on the basis of results we can
draw conclusion and recommendations for future research work into it and also the same results will be
shared with other health professionals and guidelines
and suggestions will be given for required changes in
routine management of patients of UGIB. This will help
our already compromised population with UGIB in reducing the burden of morbidity related to it.
MATERIALS AND METHODS
Settings: Department of Gastroenterology and Hepatology, Hayatabad Medical Complex, Peshawar.
Study duration: Six months
Study Design: Descriptive case series.
Sample Size: Total sample size was 140 while taking
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.
Sampling technique: Consecutive, non probability
sampling. The above mentioned conditions act as confounders and if included will introduce bias in the
study results.
SAMPLE SELECTION
Inclusion criteria:
• Age more than 15 years.
• Upper gastrointestinal bleeding on initial assessment.
• Either gender.
Exclusion criteria:
• Acute myocardial infarction, trauma, stroke and
other conditions in association with upper gastrointestinal bleed.
• Variceal bleeding on endoscopy.
• Cause not identified on endoscopy.
116
•
Developed bleeding during hospital stay for some
other diagnosis.
RESULTS
This study was conducted at Gastroenterology
Department Hayatabad Medical Complex, Peshawar
in which a total of 140 patients were observed to determine the high Glasgow Blatchford scoring system
and its one month mortality in patients presenting with
non variceal upper gastrointestinal bleeding and the
results were analyzed as age distribution among 140
patients, was analyzed as 4(3%) patients were in age
ranging 20-30 years, 25 (18%) patients were in age ranging 31-40 years, 48 (34%) patients were in age ranging
41-50 years, 49 (35%) patients were in age ranging 51-60
years,14 (10%) patients were above 60 years. Mean age
was 30 years with SD ± 2.21 (as shown in Table No 1)
Gender distribution among 140 patients was analyzed
as 77(55%) patients were male and 63(45%) patients
were female. (shown in Table No 2) Status of Glasgow
Blatchford score among 140 patients was analyzed as
35(25%) patients had Glasgow Blatchford score < 12
and 105(75%) patients had Glasgow Blatchford score
more than 12. Mean Glasgow Blatchford score was 11
with SD ± 2.88 (as shown in Table No 3) Status of mortality among 140 patients was analyzed as mortality
rate was 22(16%) while 118(84%) patients were normal.
(as shown in Table No 4)
Stratification of Glasgow Blatchford score with age distribution was analyzed as in 35cases of Glasgow Blatchford score <12, 9 patients were in age range 31-40 years,
11 patients were in age ranging 41-50 years, 12 patients
were in age ranging 51-60 years and 3 patients were
more than 60 years. Where as in 105cases of Glasgow
Blatchford score> 12, 4 patients were in age ranging
20-30 years, 6 patients were in age ranging 31-40 years,
37 patients were in age ranging 41-50 years, 37 patients
were in age ranging 51-60 years and 11 patients were
more than 60 years. (as shown in Table No 5)
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
Glasgow Blatchford score> 12, 57 patients were male
and 48 patients were female. (as shown in Table No
6) Stratification of mortality with age distribution was
analyzed as out of 22 cases of mortality 10 patients
died in age range 51-60 years and 12 patients died in
age ranging more than 60 years. (as shown in Table
No 7) Stratification of mortality with gender distribution was analyzed as out of 22 cases of mortality 13
patients were male and 9 patients were female. (as
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)
Age distribution
Frequency
Table No-8: stratification of mortality in
gender distribution (n=140)
Percentage
20-30 years
4
3%
Mortality
Male
Female
Total
31-40 year
25
18%
Yes
13
9
22
41-50 years
48
34%
No
64
54
118
51-60 years
49
35%
Total
77
63
140
> 60 years
14
10%
Total
140
100%
Mean age was 30 years with SD ± 2.21
Table No-2: gender distribution (n=140)
Gender distribution
Frequency
Percentage
Male
77
55%
Female
63
45%
Total
140
100%
Table No-3: Glasgow Blatchford scoring findings (n=140)
Glasgow Blatchford score
Frequency
Percentage
< 12
35
25%
> 12
105
75%
Total
140
100%
Mean Glasgow Blatchford Score was 11 with SD ± 2.88
Table No-4: mortality (n=140)
Mortality
Frequency
Percentage
Yes
22
16%
No
118
84%
Total
140
100%
Table No-5: stratification of accuracy high Glasgow
Blatchford score in age distribution (n=140)
20-30
years
31-40
years
9
11
12
3
35
>12
4
6
37
37
11
105
Total
4
25
48
49
14
140
Accuracy
< 12
41-50
years
51-60 > 60
years years
Total
Table No-6. stratification of accuracy high Glasgow
Blatchford score in gender distribution (n=140)
Accuracy
Male
Female
Total
< 12
20
15
35
> 12
57
48
105
Total
77
63
140
Table No-7: stratification of mortality in
age distribution (n=140)
Mortality
20-30
years
31-40
years
41-50
years
Yes
51-60
years
> 60
years
Total
10
12
22
No
4
25
48
39
2
118
Total
4
25
48
49
14
140
Ophthalmology Update Vol. 13. No. 2, April-June 2015
DISCUSSION
Upper gastrointestinal bleeding is one of the life
threatening complications in patients with liver cirrhosis. 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 between the pharynx and the ligament of Treitz, characterized
by hemetemesis (vomiting up blood) and melena (tarry stool
containing altered blood). Gastrointestinal endoscopy
remains the diagnostic and therapeutic procedure of
choice for UGI bleeding. The epidemiology of various
causes of upper G.I. bleeding has been changing in recent 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 medical education and learning. Risk scoring systems are
not used commonly in daily practice in the ED for the
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,
the use of blood transfusion and the necessity of emergent endoscopy. In this regard, as GBS scores may be
calculated easily based only on clinical and laboratory
variables, this system seems to be suitable for use in the
ED.
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
the sensitivity of the GBS system in the differentiation
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 patients for a cut-off value of GBS >12. In our study, the
number of the subjects with UGI system bleeding with
a GBS score ≤12 was 25% and, in this group of patients,
none of the subjects that underwent endoscopy showed
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
117
Frequency of High Glasgow Blatchford Score & its One Month Mortality in Patients presenting
ED. While the retrospective study performed by Sriraj
Askanthan et al.22 revealed a cut-off value of GBS ≤12 in
the differentiation of low-risk patients among the patients with UGI system bleeding, other studies23,24 used
GBS=0 in the differentiation of the low-risk patients.
An ideal scoring system should have both a good
sensitivity and high specificity. However, in the studies conducted, the sensitivity and specificity of the GBS
system vary among high-risk patients with UGI system
bleeding.25,26 In our study, the sensitivity and specificity
were 100% and 1.41% for a cut-off value of GBS >12,
100% and 16.9% for a cut-off value of GBS >3, 96.63%
and 36.62% for a cut-off value of GBS >5, and 86.52%
and 69.01% for a cut-off value of GBS >8. In the study
performed by Chen et al.27 positive predictive value
(PPV) and negative predictive value (NPV) for GBS
>0 were 75.2% and 96.4%, respectively. In the study
conducted by Farooq et al.28 PPV and NPV were 37%
and 100%, respectively for GBS >0 and 42% and 82%
for GBS >5. In our study, PPV and NPV were 56% and
100% for GBS >0 and 65.6% and 89.7% for GBS >5, respectively. In our study the mortality rate was 16% and
the those patients were more than 50 year of age similar
results were found in other studies in which the mortality rate was 11% and 13%,29,30
In the study performed by Hsu et al.29 in cirrhotic
patients with UGI system bleeding, six prognostic factors were determined: male gender, hepatocellular
carcinoma, non-hepatocellular carcinoma, hypoxemia,
serum bilirubin level, and PT. The investigators reported that these six clinical parameters might be easily
obtained in the ED and be valuable in the early risk determination in cirrhotic patients with acute UGI system
bleeding. For the model used in the aforementioned
study, the sensitivity was 22.73% and the specificity
was 99.8%. In our study, which did not enroll only cirrhotic patients with UGI system bleeding, but instead
all patients with UGI system bleeding and in whom the
GBS system was used, the sensitivity and the specificity
were 86.52% and 69.0%, respectively, for GBS>8, and
thereby, GBS seemed more sensitive.31
Although in the literature, there has been no consensus on the best scoring system in various studies performed using the Rockall scoring system and/or the
GBS system,19 the GBS system seems to be more useful, especially in patients with non-variceal UGI system
bleeding. In our study, which included all the patients
with non-variceal UGI system bleeding, we used the
GBS system, and found it useful in the differentiation of
high-risk patients. The limitations of this study include
the single centered design, small number of patients,
the fact that all the patients did not undergo an endos118
copy, and the enrollment of the patients to the followup based only on their conclusions in the ED.
In light of the data obtained from this study, we can state
that the patients with UGI system bleeding who have
a GBS score ≤3 may be safely discharged from the ED
and referred to the polyclinic to undergo an endoscopy.
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.
REFERENCES
1.
Mitchell S. Cappell, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation to gastrointestinal endoscopy. Med Clin N Am 2008:491-509.
2.
Ferguson CB, Mitchall MB. Non-variceal upper gastrointestinal
bleeding. Ulster Med J 2006;75:32-9.
3.
Manguso F, Riccio E, Bennato R, Picascia S, Fiorito R, Martino
R et al. In-hospital mortality in non-variceal upper gastrointestinal bleeding Forrest I patients. Scandinavian J Gastroentol
2008;43:1432-41.
4.
Thomas F, Imperiale, Jason A, Dominitz, Dawn T, Provenzale
et al. Predicting poor outcome from acute upper gastrointestinal hemorrhage. Arch Inter Med 2007;167:1291-6.
5.
Celinski K, Cichoz-Lach H, Madro A, M. Slomka M, KasztelanSzczerbinska B, T.Dworzanski T. Non-variceal upper gastrointestinal bleeding guidelines on management. J Physiol Pharmacol 2008;59:215-29.
6.
Van leerdam ME. Epidemiology of acute upper gastrointestinal
bleeding. Best Pract Res Clin Gastrointerol 2008:22:209-24.
7.
Bardou M. .Management of acute non-variceal upper gastrointestinal bleed. Indian J Gastroenterol 2006;25:22-4.
8.
Talafeeh A, Eweis S, Holy M. Endoscopic finding in upper
gastrointestinal bleeding patients at Prince Hashim Hospital. J
Rawal Med Sci 2004;1:71-3.
9.
Adam T, Javed F, Khan S. Upper gastrointestinal bleeding: An
etiological study of 552 cases. J Pak Inst Med Sci 2004;15:845-8.
10. Chaudhry AW, Tabassum HM, Chaudhry MA. Pattern of upper gastrointestinal bleeding at Rahim Yar Khan. Ann King Edward med Coll 2005;11:282-3.
11. Selinger CP, Ang YS. Gastric antral vascular ectesia (GAVE):
an update on clinical presentation, pathophysiology and treatment. Digestion 2008;77:131-7.
12. Stojakov D, Velickovic D, Sabljak P, Bjelovic M, Ebrahimi K,
Spica B et al. Diciulafoy’s lesion: rare cause of massive upper
gastrointestinal bleeding. Acta Chirr Lugosol 2007;54:125-9.
13. John G Lee. What is the value of early endoscopy in upper gastrointestinal bleeding? Nat Clin Pract Gastroenterol hepatol
2006;3:534-5.
14. Donner MW, Bosma JF, Robertson DL. Anatomy and physiology of the pharynx. Gastrointest Radiol 1985;10:196.
15. Ekberg O, Lindstrom C.The upper esophageal sphincter area.
Acta Radiol 1987;28:173.
16. Boyce H. Endoscopic definitions of esophagogastric junction
regional anatomy. Gastrointest Endosc 2000;51:586.
17. Kim T, Shijo H, Kokawa H. Risk factors for hemorrhage from
gastric fundal varices. J Hepatol 1997;25:307-12
18. Toyonaga A, Iwao T. Portal hypertensive gastropathy. J Gastroenterol Hepatol 1998;13:865–77.
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19.
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Primignani M, Carpinelli L, Preatoni P. Natural history of portal hypertensive gastropathy in patients with liver cirrhosis.
The new Italian endoscopic club for the study and treatment
of esophageal varices (NIEC). J Gastroenterol 2000;119:181-7.
Beck PL, McKnight W, Lee SS. Prostaglandin modulation of the
gastric vasculature and mucosal integrity in cirrhotic rats. Am
J Physiol 1993;265:453-8.
Nasir N, Nadeem MA, Imran M, Hussain I, Chaudhry NU. Oesophageal varices Vs peptic ulcer: A Study of 100 Patients Presenting in Mayo Hospital with Upper Gastrointestinal Bleeding. Pak J Gastroenterol 1998; 2:0-.
Shahin WA, Abdel-Baset EZ, Nassar AK, Atta MM, Kabil SM,
Murray JA, Low incidence of Helicobacter pylori infection in
patients with duodenal ulcer and chronic liver disease. Scand J
Gastroenterol. 2001;36:479-84.
Gravante G, Delogue D, Vanditti D. Upper and lower gastrointestinal
diseases in liver transplant candidates. Int J
Colorectal Dis 2008;32:201-6
Srirajaskanthan R, Conn R, Bulwer C, Irving P. The Glasgow
Blatchford scoring system enables accurate risk stratification
of patients with upper gastrointestinal haemorrhage. Int J Clin
Pract 2010;64:868-74.
Masaoka T, Suzuki H, Hori S. Blatchford scoring system is a
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useful scoring system for detecting patients with upper gastrointestinal bleeding who do not need endoscopic intervention. J
Gastroenterol Hepatol 2007;22:1404-8.
Chen IC, Hung MS, Chiu TF. Risk scoring systems to predict
need for clinical intervention for patients with nonvariceal
upper gastrointestinal tract bleeding. Am J Emerg Med 2007;
25:774-9.
Farooq FT, Lee MH, Das A. Clinical triage decision vs risk
scores in predicting the need for endotherapy in upper gastrointestinal bleeding. Am J Emerg Med 2012;30:12934.
Hsu YC, Liou JM, Chung CS. Early risk stratification with simple clinical parameters for cirrhotic patients with acute upper
gastrointestinal bleeding. Am J Emerg Med 2010;28:884-90.
Gralnek IM, Dulai GS. Incremental value of upper endoscopy
for triage of patients with acute non-variceal upper-GI bleeding. Gastrointest Endosc 2004;60:9-14.
Pang SH, Ching JY, Lau JY. Comparing the Blatchford and preendoscopic Rockall score in predicting the need for endoscopic
therapy in patients with upper GI bleeding. Gastrointest Endosc 2010;71:1134-40.
Tham TC, James C, Kelly M. Predicting outcome of acute nonvariceal upper gastrointestinal haemorrhage without endoscopy using the Rockall Score. Postgrad Med J 2006;82:757-9.
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Ophthalmology Update Vol. 13. No. 2, April-June 2015
119
ORIGINAL ARTICLE
Meatal Mobilization Technique for
Childhood Hypospadias Repair, an Early
Experience at Lady Reading Hospital, Peshawar
Ayub Khan
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
ABSTRACT
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 stenosis. 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.
INTRODUCTION
Distal Hypospadias accounts for 50-60% of all
forms of hypospadias. with an increasing incidence being present in 1 out of 125 male newborns Of those, 15%
are glanular, 50% coronal, 30% subcoronal,and 5% are
of the megameatus intact prepuce (MIP) variant.1 The
goal of modern hypospadias repair is to achieve functionally as well as cosmetically normal looking glans,
meatus and phallus.2 Generally, the surgical technique
of choice is decided upon meatal location, the appearance of the meatus relative to the glans, the presence
or absence of chordee, and the quality of the preputial
hood. the meatal mobilization (MEMO) technique was
developed to correct coronal and subcoronal hypospadias. According to the technique of the meatus mobilization, this operation Method referred to as MEMO,
based on the work by Beck 1898.3 This approach comAssociate Professor, Paeds Surgery, 2Medical Officer, Paeds Surgery
unit Govt. PGMI LRH Peshawar. 3Senior Registrar Surgical C unit,
Khyber Teaching Hospital, Peshawar. 4Assistant Professor, Paeds
Surgery, 5Senior Registrar, Paeds Surgery, 6Junior Registrar, Paeds
Surgery, 7Medical Officer, Paeds Surgery, 8Resident Paeds surgery,
Postgraduate Medical Institute, Lady Reading Hospital PeshawarPakistan.
1
Correspondence: Dr. Muhammad Ayub Khan, FCPS(Paeds Surgery)
Associate Professor, Paeds Surgery, PGMI LRH Peshawar.
Cell: 0300-5979070, E-mail: akpsurgeon63@gmail.com
Received: January 2015
120
Accepted February 2015
bines meatal mobilization by distal urethral dissection
with steps of previously established techniques, e.g. a
rotational flap for fashioning the Firlit preputial collar
and straight-forward glanuloplasty.4,5 The aim of this
study was to determine the short term results of memo
hypospadias repair for distal penile hypospadias in
children.
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.
MATERIALS AND METHODS
This descriptive study was conducted in the paediatric surgery unit, Lady Reading Hospital, Peshawar over a period of eight months from June 2009 to
February 2010. Non probability sampling techniques
was used. Children between 2 and 14 years, with distal penile hypospadias with or without chordee were
included and those who had proximal hypospadias
i.e midshaft penoscrotal and perineal hypospadias
were excluded from the study .All those patients fulfilling inclusion criteria of this study whose parents
gave informed consent after explanation of the whole
protocol, benefits versus risks of surgery were admitted through the outpatient department of the hospital.
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 investigation i.e., Haemoglobin, urine R/E, HBs Ag, anti HCV
antibodies and other relevant investigation if necessary
were also done All patients were operated under general anesthesia. A tourniquet was applied to maintain
a bloodless field and a 3/0 prolene stay suture taken
into glans for traction and later to secure the urethral
stent An intra-urethral Stent is inserted and skin incision is performed in a cicumurethral fashion.The initial
dissection of the penile skin is started dorsally along
Buck`s fascia until the base of the penis is reached. The
key step of the procedure is assessment of distal urethral mobility after penile skin dissection. Only with an
appropriately mobile urethra the MEMO technique can
be performed. The meatus is incised circumferentially
starting laterally on both sides of the meatus. The corporal bodies represent the dorsal plane of mobilization.
Along this plane dissection is easy and is performed 1
to 1.5 cm proximally (Fig. 1-4). The length of mobilization depends upon the mobility of the urethra, but
dissection should not be done too far proximally avoiding curvature and fistula formation. Following mobilization the meatus is easily brought up to the tip of
the glans. Incision of the glans up to the tip is followed
by excision of excess mucosa on both sides. Dissection of glanular wings allows tension free rotation of
glanular tissue to cover the underlying urethra . Using
6-0 vicryl interrupted sutures adaptation of glanular
und urethral epithelium is performed. Glanuloplasty
is accomplished with two or three 6-0 vicryl sutures.
It brings spongy tissue ventrally covering the urethra
while a conic glans is constructed. Circumcision was
performed. Sterile dressing was performed around the
penis and remains in place overnight. Patients were followed for three months. with their first visit commencing at the 7th day postoperatively for the removal of the
stent in out patients department. The next visits were
scheduled on 1st and 3rd months in the outpatient department All patients were followed for any complication and documented in a predesigned proforma for
each patient. All data was analyzed by using SSPS ver-
Fig-1
Fig-2
sion 16. Age of patient and the time taken for operative
procedure was analyzed for mean and standard deviation any complication were expressed in frequencies
and percentages data.
RESULTS
A total of 60 patients with distal penile hypospadias were analyzed for age, operative time and postoperative complications. All these patients were in the
age range from 2 to 10 years. Mean age was calculated
3.9 years ± SD 1.86. Mean operative time was 47 minutes (33-56 minutes). Mean duration of hospitalization
was1.5 days (1 to 3 days). There were no complications
during surgery in any of the patients. The overall rate
of urethra-cutaneous fistula was 5% (3 in 60 patients)
two of these patients were treated successfully with
weakly meatal dilation under topical xylocaine anesthesia for four weeks remaining one patient underwent
for successful surgical correction of fistula repair after
6 months. three patients had a minor complication of
preputial edema in which circumcision was not performed all of these patients were treated conservatively by dressing, two patients had local hematoma, which
was treated conservatively by compressive dressing;
one of the patient noted a split urinary stream which
was improved by topical application of petroleum jelly.
Cosmetic appearance of the glans, meatus and phallus
were acceptable.
DISCUSSION
The MEMO technique, based on a procedure first
described by Beck , allows for correction of most coronal and subcoronal hypospadias without tubularizing
the urethra or applying a some flap procedure.1,3 Utilization of this procedure was not consistently successful
because of the high incidence of postoperative chordee
due to inadequate mobilization of the urethra.6 Numerous ingenious methods for urethral advancement
were reported by many authors.7,8 The ventral aspect
of the urethra should not be too flimsy and the urethra
should be mobile enough for this procedure. This maneuver additionally creates a cosmetically appealing
conical shape of the glans.1
Fig-3
Fig-4
Diagrammatic representation of MEMO-technique
Ophthalmology Update Vol. 13. No. 2, April-June 2015
121
Meatal Mobilization Technique forChildhood Hypospadias Repair, an EarlyExperience at Lady Reading Hospital, Peshawar
The fact that more than 300 different operations
are described in the literature reflects the wide spectrum of the anomaly, and proves that the treatment
has not been perfected.6 In the presented study, 60 boys
underwent surgery using the MEMO technique. No
urethral stricture noted in all operated patients, three
patients developed urethrocutaneuous fistula, two of
these patients responded well with weakly meatal dilatation under topical anesthesia and hence not requiring any major surgical correction, the remaining one
patient was subjected to successful operative repair of
fistula after failure of conservative management after 6
months of initial repair.
Overall rate of urethra-cutaneous fistula post
MEMO repair was 5% in our series compared to Seibold etal who reported a fistula rate of 1%­.1 This high
rate of urethra-cutaneous fistula post MEMO repair in
our series compared to Western studies might be the
early learning curve of authors ,as a thorough literature
search was made to compare our results with the local
studies.No satisfactory local studies were available to
compare our results with local results.
CONCLUSION
Over 80 percent of boys with this condition have
distal hypospadias, and the successful repair of distal
hypospadias can be easilly achieved by meatal mobilization technique which is a single stage procedure having low complication rate,good cosmetic results and is
technically simple to learn.
REFRENCES
1. Seibold J, Amend B, Saladin , Alloussi H S, Colleselli D,
Tode hoefer T, Gakis G, Merseburger A, Sievert DK, Stenzl
A, Schwentner C. Meatal mobilization (MEMO) technique for
distal hypospadias repair: Technique, results and long-term
follow-up. CEJU March 2010; 63 :125-28.
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Uzair M, Ahmad M, Hussain M, Younus M, Khan K. Frequency of urethrocutaneous fistula following snodgrass hypospadias repair in children. JPMI 2013; 27(1):74-77.
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Beck C. A new operation for balanic hypospadias. NY Med J
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Seibold J, Boehmer A, Verger A et al. The meatal mobilization
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Redman JF. A favorable experience with rotational flap techniques for fashioning the Firlit preputial collar. J Urol 2006; 176:
715-717.
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Elemen L, Tugay M. Limited Urethral Mobilization Technique
in Distal Hypospadias Repair with Satisfactory Results, Balkan
Med J 2012; 29: 21-5
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Hamdy H, Awadhi MA, Rasromani KH. Urethral mobilization
andmeatal advancement: a surgical principle in hypospadias
repair.Pediatr Surg Int 1999;15:240-2.
8.
Atala A. Urethral mobilization and advancement for midshaft
todistal hypospadias. J Urol 2002;168:1738-41.
Ophthalmological Society of Pakistan, KPK Branch
is holding the next Ophthalmic Symposium at
Nathiagali, KPK
From 7-9 August 2015
Please contact:
Dr. Mir Ali Shah, Associate Professor
Department of Ophthalmology, Lady Reading Hospital, Peshawar.
Cell : 03005948091, Email: drmashahpsh@gmail.com
122
Ophthalmology Update Vol. 13. No. 2, April-June 2015
OBITUARY
‫اﺟ ُﻌ ﻮن‬
ِ ِ ‫ِاَﺎ‬
ِ َ ‫ﷲ َو ِاَﺎ ِاﻟَﻴ ِﻪ‬
َ
Ah!
Forever Loved - Forever Missed
Prof. M. Naseem Ullah
FCPS, FRCP
Prof. M. Afzal Farooqi
FCPS, FRCS
Principals of Rawalpindi Medical College
Recently, the death of Prof. M. Naseem Ullah
and Prof. M. Afzal Farooqi, both Principals of Rawalpindi Medical College, was widely mourned in
the twin city of Islamabad and Rawalpindi, especially by the medical community at the large. They
were the teachers of teachers and great mentors in
their respective fields. Hundreds of students, doctors, professors and representatives of Governmental and pharmaceutical institutions attended the funeral. They earned fame through their professional
skill and commitment.
Prof. M. Naseem Ullah served as Professor of
Medicine, he had a special interest in academic and
research work. After retirement he joined Islamabad Medical & Dental college as Prof. of Medicine
& Dean of the faculty. His contributions to the profession will be ever remembered
Prof. M. Afzal Farooqi served as Professor of
Ophthalmology Update Vol. 13. No. 2, April-June 2015
Urology. He is well known in the medical fraternity as the best surgeon in the twin cities. With
his death the college is deprived of his guidance
and support . He was bestowed with a high sense
of honor and integrity for the collective goal of our
institution.
The editorial board and the management of
Ophthalmology Update, bring on record the services of these professors who were responsible for
the development and progress of the college in its
formative years. We announce the untimely demise of our highly revered professors, impeccable
teachers and charismatic personalities with profound grief and sorrow. Both the professors were
embodiment of simplicity and role model of medical education. May All bless their souls in peace
and paradise..............Amin!
Chief Editor
123
Murree:
The Queen of Mountains - A Shining Pearl of Pakistan
(Malika-e-Kohsaar)
It is not only a hill station but also a tourist paradise. It is a true example of natural beauty. The mind
and soul refreshes when you see the green beauty covered 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 communication network, resort hotels, golf course and chairlift/cable cars. Murree and Gallies are a wonderful retreat from the hot weather of the plains in summer.
Speculations abound on how Murree got its name,
some scholars (according to Virgil Miedema, published
in his book: ‘Murree - A glimpse through the Forest’
published by Maple-Books, New Deihi in 2002, and
the excerpts carried on by Mr. Ansar Saleem in an
English Daily ‘DAWN’ in 2014 from pages 13-18 highlighted on the topic “Pages from the History”) say that
the name is a corruption of the word Mary or Mariam
who died at the age of 70 and buried in a tomb at Pindi
Point. According to Mr. Abdul Latif, Chief officer of the
Municipal Committee, Murree skeptically said at the
time of centenary celebrations of Murree in 1967 that
Mary roamed thousand years ago in the thick forests of
Murree en route to Kashmir. In fact there is an evidence
in the records of Municipal committee of a dispute over
the alleged tomb. In 1858 the British built a watch tow-
Sunset at Murree Hills
124
After snow fall at the Hills
er near the monument and in 1917 Captain Richardson
passed an order to demolish the tomb in order to keep
the pilgrims away. There were protests and the demolition was stopped. In 1950 the tomb was rebuilt but the
watch tower was removed. Today, there is television
transmitter looming over the tomb.
More prosaic explanations for the names abound
as well. Murree is a Turkish word meaning “pasture”. It
may come from the Urdu or Arabic, meaning an abode
or a place, like in Shalimar, a place of happiness, it may
come from the English word “Merry” from an English
Officer Mr. Murray, or from “Murreey” after the purple
or mulberry-colored mountains. In Hindi and the local
dialect Marhi means a high place, this Marhi being the
original grazing ground for the villages of Mooseearee
raised in 1826, Mohra Sharif, Dewal Sharif and Aliot.
Lying on the outskirts of the Himalaya, the Murree 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 District, 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.
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
Murree as a sanatorium. In 1851, Murree was selected
as the summer headquarters of Punjab. The Mall was
established in 1850, is the centre of shopping area,
where most people congregate. Good buys in Murree
are Kashmiri shawls, furs, walking sticks, fruits and
nuts. Murree’s pistachio nuts are reputed to be the best
in Pakistan.
The Imperial summer capital was popularized by
Rudyard Kipling- a noble laureate from Lahore and
Chief Editor of an English daily “Civil & Military Gazette an English Daily” being published from Lahore.
Dane Kennedy commented: ‘Located on peaks that
loom like sentinels over heat-shimmering plains. Murree remains among the most curious monuments to the
British colonial presence in the area. The Saumly Sanatorium was primarily established for the European invalids, but hill stations soon assumed an importance
that far exceeded the therapeutic attraction. To these
cloud-enshrouded sanctuaries the British expatriate
elite but also to familiarize with the alien culture with
the locals living in areas like Aliot, a village 2 kilometer down the Bhurban. Here they established political
headquarters and military cantonments and centers
where from they issued executive orders.
In 1845 Murree was brought under the control of
East India Company rule and after the Treaty of Lahore
(March 9, 1846), the first resident in the Punjab was
Henry Lawrence, later founder of the famous Lawrence
schools in Ghora Gali (Murree), Abbotabad & Lawrence gardens in Lahore came to Murree. The “Rules
Ophthalmology Update Vol. 13. No. 2, April-June 2015
for the Administration of Murree Town” were framed
in 1851, which allowed for a Murree Sanatorium Committee to be established at Saumly. A total reduction
in land revenue of Rs.114.40 and cash compensation of
Rs.1,935 was proposed for Ilyot and Mooseeareeareas
and adjoining areas. This was approved by the Chief
Commissioner of the Punjab. A special grant was proposed in the form of a cash lease payment of Rs.50 per
annum in perpetuity. Upon the conclusion of protracted
negotiations with the villagers, the proposal went to
Calcutta for final approval. Finally, this annual payment
was approved by the Governor-General, Lord Dalhousie, by an order dated November 23, 1855. The story goes
that the original bargain with the people of that area was
actually for Rs.60 per annum as lease payment, instead
of Rs.50. Since the Maim Sahiba (Lord Dalhousie’s wife)
being a British national, was poorly attired according to
the Muslim customs of the area, the villagers offered
Rs. 10/- for the purchase of Shalwar, Kameez and a
shawl for the Maim Sahiba to dress her properly.
By 1850, more than 50 bungalows had been constructed towards Kashmir Point, Pindi Point and along
Kuldannah Road. In 1851, troops were first quartered
in Murree, and permanent barracks were erected in
1853. Holy Trinity Church on the Mall (Jinnah Road)
was opened on May 17, 1857., and the first Sunday
Mass service was served.
REFERENCES:
1. Mr. Salim Ansar ‘Pages from the history’, The News, Lahore. 2. Mr. Arshad Mahmood Abbasi, former: Nazim of Union Council, Murree.,
3. Murree — A Glimpse Through the Forest by Virgil Miedema
125
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